Dependent Day Care Flexible Spending Account Reimbursement Request Form

Dependent Day Care Flexible Spending Account Reimbursement Request Form - Dc

Dependent Day Care Flexible Spending Account Reimbursement Request Form - DC

(See instructions on reverse side)

A. EMPLOYEE INFORMATION

CIGNA ID NUMBER OR EMPLOYEE SOCIAL SECURITY NUMBER

EMPLOYER NAME (Required)

ACCOUNT NUMBER(S)

(on the front of your CIGNA ID card) (Required)

LAST NAME

FIRST NAME

ADDRESS

CITY

STATE

ZIP/POSTAL CODE

B. DEPENDENT DAY CARE EXPENSES

IF DAY CARE IS PROVIDED BY ONE OF YOUR CHILDREN, PLEASE PROVIDE THAT CHILD’S AGE: ______________

DEPENDENT

PROVIDER NAME AND ADDRESS

DATE(S) OF

TYPE OF

DEPENDENT NAME

BIRTH DATE

AGE

(i.e., Day Care Facility Name)

SERVICE

Total Reimbursement Request:

Day Care Provider’s Signature: The day care provider’s signature can be substituted for the receipt. Name, address and Tax ID # will

be required on Tax Form 2441 in order to obtain the tax advantage for these expenses.

PROVIDER’S SIGNATURE (Required if receipt is not provided)

PROVIDER TAX ID OR SSN (Required if receipt is not provided)

C. CERTIFICATION

I certify that the expenses for which I am requesting reimbursement are for dependent day care expenses which qualify for

reimbursement under the Internal Revenue Code and are eligible to be excluded from my federal taxable wages (see reverse of

this form for a summary of IRC requirements; consult the IRC or your tax advisor for a more detailed explanation of these

requirements). I further certify that these expenses have been incurred by me, they have not been previously submitted for

reimbursement, and they have not been reimbursed from any other source, nor do I expect them to be. I agree to notify the

CIGNA HealthCare Reimbursement Account Unit immediately if any of these expenses are reimbursed from any other source.

EMPLOYEE SIGNATURE (Required - unsigned Reimbursement Request Forms will not be considered for reimbursement)

DATE

589114a Rev. 3-06

Dependent Day Care Flexible Spending Account Reimbursement Request Form - Dc