Qualified Parking Expense Reimbursement Form

Qualified Parking Expense Reimbursement Form

Page

of

EMPLOYEE NAME: LAST

FIRST

MIDDLE INITIAL

COMPANY NAME

J check if new

LAST FOUR DIGITS OF SOCIAL SECURITY NO.

DAYTIME PHONE NUMBER

EMAIL ADDRESS

J check if new

HOME ADDRESS: STREET

CITY

STATE

ZIP

To the best of my knowledge and belief, my statements for reimbursement are complete and true. I am claiming reimbursement only for eligible expenses incurred or paid to park my

car on or near the business premises of my employer or Expenses Incurred or paid to park my car on or near a location from which I commute to work. I certify that these expenses have

not already been reimbursed. If there is a discrepancy between the total amounts of receipts requested below and the total amount of the attached receipts, I will be reimbursed

according to the total amount of eligible expenses on the attached receipts.

X

EMPLOYEE SIGNATURE VERIFICATION ( R eceipts will not be processed without signature)

DATE

STEP 1:

This section of the reimbursement form must be completed only for eligible expenses and only for expenses incurred during your plan year. You must have been a

participant in the plan at the time the expense was incurred. The incurred date of the expense is the date of service. This form is for Qualified Parking Expenses Only.

Receipts must include the following information:

K Be sure to total your expenses

K Date of Service

K Parking Location

K Canceled checks/credit card statements are not acceptable

K Parking Provider

K Amount of Service

forms of documentation

DATE OF SERVICE

PARKING PROVIDER

PARKING LOCATION

AMOUNT

$

.

From:

❒ Check this box if no receipt was

provided in the normal course of

To:

business (parking meter or drop box).

$

.

From:

❒ Check this box if no receipt was

provided in the normal course of

To:

business (parking meter or drop box).

$

.

From:

❒ Check this box if no receipt was

provided in the normal course of

To:

business (parking meter or drop box).

$

.

From:

❒ Check this box if no receipt was

provided in the normal course of

To:

business (parking meter or drop box).

$

.

From:

❒ Check this box if no receipt was

provided in the normal course of

To:

business (parking meter or drop box).

STEP 2: Please fax to 888.267.0839

For the quickest processing time, complete, sign and fax your reimbursement

form and all necessary documentation. A cover page is not required. Claims will be processed within two business days of receipt. If you prefer to

mail your form and receipts, please send to PO Box 527, Ada, MI 49301. Please keep all receipts and original documentation as required by the IRS.

Questions? Please contact Next Generation Enrollment, Inc. at 888-266-1732 Monday through Friday between the hours of

8:00 AM and 8:00 PM EST.

Delivered By Next Generation Enrollment, Inc. 9.13