Fillable Reimbursement Request Form printable pdf download

Reimbursement Request Form

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121 Benefits • 730 2

Ave. S. Ste. 400 • 730 Building • Minneapolis MN 55402-2446

Phone: 612.877.4321 • Toll-Free Phone: 800.300.1672

Fax: 612.877.4322 • Toll-Free Fax: 877.918.3622 •

EIMBURSEMENT

EQUEST

ORM

Please Complete All Information And Attach Itemized Documentation For Each Expense Listed

Benefit Year: ________ Employer: Hennepin County

Social Security Number: XXX – XX - _______ First Name: __________________ MI: ___ Last Name: ____________________________

Address: __________________________________________________ City: _________________________ State: ____ Zip: ________

Daytime Phone: ______________________________ Email: ______________________________________________________________

Unreimbursed Medical/Dental Expenses (for you, your spouse and your dependents)

Date(s) of Service

Person for Whom

Net

(MM/DD/YY)

Expense Incurred

Expense Description

Name of Service Provider

Amount*

Note: If you need additional space, please

Total Unreimbursed Medical/Dental Expense Claimed

attach a separate sheet of paper.

*Net amount is the amount of the claim not reimbursed to you through another plan; i.e. health or dental insurance.

Unreimbursed Dependent Care Expense (Daycare Expenses)

Read Carefully

Period Covered

Identify below the Provider Name, Tax ID and Signature

Actual

The undersigned participant in the

OR attach a receipt from the Provider with the Provider

from

Name of Dependent

Amount

plan certifies that all expenses for

Name, Tax ID and Signature. The information is required

which reimbursement of payment is

(MM/DD/YY) to (MM/DD/YY)

Incurred

with each submission.

claimed by submission of this form,

were incurred during a period while

the undersigned was covered under

Provider Signature:

the company’s cafeteria plan. The

undersigned fully understands that

he/she alone is responsible for the

Provider Signature:

sufficiency, accuracy, and veracity of

all information relating to this claim

which is provided by the undersigned

Provider Signature:

and that, unless an expense for which

Note: If the same Dependent Care

payment of reimbursement is claimed

Total Unreimbursed Dependent Care Expense Claimed

Provider for each claim is listed

is a proper expense under the plan, the

above, signature is required only

undersigned may be liable for payment

once.

of all related federal, state, or city

income tax on amounts paid from the

plan which relate to such expense.

Employee Please Sign Here

Date

Rev. 10/2016

Reimbursement Request Form

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