Fillable Reimbursement Request Form - 121 Benefits printable pdf download

Reimbursement Request Form - 121 Benefits

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121 Benefits

730 2nd Ave. S., Ste. 400

730 Building

Minneapolis, MN 55402-2446

Phone: 800.300.1672

Fax: 877.918.3622

Reimbursement Request Form

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

Benefit Year: _______________

Employer: __________________________________________________________________

Social Security Number: XXX - XX - ____________

First Name: _______________________ MI: _______ Last Name: ____________________________________

Address: _________________________________________________________________________

City: _______________________________________ State: ____ Zip: __________________________

Daytime Phone: (_____) ____________________________

E-mail: _______________________________________________

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

Date(s) of

Person for Whom

Net Amount*

Service

Expense Description

Name of Service Provider

Expense Incurred

(MM/DD/YY)

Note: If you need additional space, attach a

Total Unreimbursed Medical/Dental Expense Claimed

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)

Identify below the Provider Name, Tax ID and Signature

Period Covered

Name of

Actual Amount

OR attach a receipt from the Provider with the Provider

Name, Tax ID and Signature. The information is required

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

Dependent

Incurred

with each submission.

Provider Signature -

Total Unreimbursed Dependent Care Expense Claim

Note: If same Dependent Care Provider for each claim listed above, signature is required only once.

Read Carefully

The undersigned participant in the plan certifies that all expenses for which reimbursement of payment is claimed by submission of this form, were

incurred during a period while the undersigned was covered under the company’s cafeteria plan. The undersigned fully understands that he/she alone is

responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned and that, unless an

expense for which payment of reimbursement is claimed is a proper expense under the plan, the undersigned may be liable for payment of all related

federal, state, or city income tax on amounts paid from the plan which relate to such expense.

Date

Employee Please Sign Here

Rev 11/2016