Form Fsa004 - Flexible Spending Account (Fsa) Reimbursement Claim - Dependent Care Allowance (Paychex)
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1FOR OFFICE USE ONLY
FAX: 585-389-7003
Docket # __________________________
Submit or view claims ONLINE:
Paychex Employee Services: 877-244-1771, available 24/7
Flexible Spending Account (FSA) Reimbursement Claim
Dependent Care Allowance
EMPLOYEE INFORMATION (print)
Employee Name _____________________________________________ Company Name _____________________________________
Social Security Number (last 4 digits) ____________________________
Employee Telephone Number (
) _________- __________
E-mail Address |
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Visit at any time to submit claims ONLINE or learn the status of your claim.
All claim reimbursements will be processed within 2 business days upon receipt of the completed claim form and all supporting documentation.
INSTRUCTIONS CHECKLIST:
If you are completing the table below, enclose copies of all itemized bills and/or receipts from your provider. Use blue or black
ink only to identify FSA items on receipts. Do not use highlighter. We will not accept copies of personal checks, cancelled
checks, or credit card receipts as verification of service.
Verify that bills and receipts contain:
•
•
•
date of service
provider’s name
dependent’s name and age
•
•
cost of service
provider’s signature
If you are not providing receipts, complete the Certification from Provider section and make sure your Dependent Care
Provider signs the form in the space provided.
Sign your claim form and fax it to the number noted above. Retain a copy for your records.
If you prefer, mail your claim to: Paychex, Inc., FSA Claims, PO Box 3000, Henrietta, NY 14467-3000.
Claim
Name of Service
Age of
Service Date(s)
Service
Service
Amount
Recipient
Service
Description
Provider
Recipient
SAMPLE
Baby Doe
1 year
7/7/07 – 7/14/07
Dependent Care
Ms. Smith
$210.43
01
Dependent Care
$
02
Dependent Care
$
03
Dependent Care
$
04
Dependent Care
$
05
Dependent Care
$
TOTAL
$
Note:
Dependent Care Claims will be reimbursed up to the year-to-date contributions made to your account at the time of submission.
If you submit for dates of service in the future or for amounts above your current contribution balance, reimbursement will
automatically be issued once the date has passed and/or additional contributions have been made for this plan year.
If you have more claims, please complete additional Reimbursement Claim forms.
CERTIFICATION FROM PROVIDER
We certify that we are providing Dependent Care Services for the employee noted above for the
month of __________________ in the year of________________ for ____________________________________ , age ____________ .
Dependent’s Name
Dependent’s Age
Dependent Care Services are custodial care for a dependent under age 13 or a dependent that is incapable of self care, and is not for
school tuition. Before/after school care is a qualified expense and should be itemized to break out from cost of school tuition if applicable.
Name of Dependent Care Provider __________________________________________________________________________________
Signature of Dependent Care Provider _________________________________________
Date ________ /_________ / ________
CLAIM INFORMATION
I incurred the expenses listed above for reimbursement on behalf of my dependent for reimbursable items under Section 125 of the Internal
Revenue Code.
Employee Signature ____________________________________________________
Date _________ / _________ / _________
FSA004 8/09
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