Flexible Spending Account Claim Form Dependent Care

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Flexible Spending Account
Claim Form ~ Dependent Care
OSR 5-344 (Rev 1-4-2010)
Employee’s Name ______________________________________________________
Social Security Number ________________-___________- _____________________
Employee’s Daytime Phone (__________) __________________________________
Please refer to the instructions on the back of this form to ensure you attach all required documents.
Dependent’s Name
Sex Birthdate
Provider Information
Dependent Care Provider Name _______________________
Address ___________________________________________
Provider Federal Tax ID# or SSN _______________________
1)
Dates of Services: From ____________ To _____________
Amount Requested: $ ________________________________
Dependent Care Provider Name _______________________
Address ___________________________________________
Provider Federal Tax ID# or SSN _______________________
2)
Dates of Services: From ____________ To _____________
Amount Requested: $ ________________________________
Dependent Care Provider Name _______________________
Address ___________________________________________
Provider Federal Tax ID# or SSN _______________________
3)
Dates of Services: From ____________ To _____________
Amount Requested: $ ________________________________
Dependent Care Provider Name _______________________
Address ___________________________________________
Provider Federal Tax ID# or SSN _______________________
4)
Dates of Services: From ____________ To _____________
Amount Requested: $ ________________________________
EMPLOYEE CERTIFICATION
I authorize my Flexible Spending Account (FSA) to be reduced by the amount of expenses listed above.
The expenses incurred by myself or my eligible dependents are not reimbursable from any other source.
I understand that these expenses cannot be claimed as credits or deductions on my income tax return.
I further certify that I have read and understand the information outlined on the back of this form. The
information on this form is true and correct to the best of my knowledge.
Employee’s Signature _______________________________________
Date ___________________

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