Form Fsa004 - Monthly Dependent Care Claim - Flexible Spending Account (Paychex)
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1FOR OFFICE USE ONLY
Docket #_______________________________
Monthly Dependent Care Claim
Flexible Spending Account
EMPLOYEE INFORMATION (print)
Office/Client Number
/
_
Employee Name _____________________________________________ Company Name ____________________________________
Social Security Number ______________________________________
Employee Phone Number (
)
REMINDERS:
MAIL TO:
•
Paychex, Inc.
Sign your claim form, and retain a copy for your records.
Section 125 Department
•
All claim reimbursements will be processed within 10 business days upon receipt of the
FSA Claims
completed claim form and all supporting documentation.
1175 John Street
•
Dependent Care claims will be reimbursed to the participant up to the balance available in the
West Henrietta, NY 14586
account.
Fax: 1-585-654-3205
•
Claims must exceed $25.00 before reimbursement will be processed.
•
Provider’s Federal ID or Social Security Number MUST be provided.
If you have any questions, visit , phone the Paychex Flexible Spending Account Information Line at
1-888-712-0088, or contact the Client Service Center at 1-877-244-1771.
CLAIM INFORMATION
Date
Weekly Amount
Week 1
/
/
to
/
/
$ ______________________________
Week 2
/
/
to
/
/
$ ______________________________
Week 3
/
/
to
/
/
$ ______________________________
Week 4
/
/
to
/
/
$ ______________________________
Week 5
/
/
to
/
/
$ ______________________________
Total Monthly Amount
$ ______________________________
I incurred the expenses listed above for reimbursement on behalf of my dependent for properly reimbursable items under section 125
of the Internal Revenue Code.
Employee Signature _____________________________________________________
Date
/
/
CERTIFICATION FROM PROVIDER
We certify that we are providing Dependent Care Services for the above employee for the
month of _______________ in the year of________________for ____________________________________ , age __________
Child’s Name
Child’s Age
Name of Day Care Provider __________________________________________________________________________________
Federal ID or Social Security Number __________________________________________________________________________
Signature of Day Care Provider ____________________________________________
Date
/
/
FSA004 7/06
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