DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIM
County of Ventura, State of California
Do not complete shaded areas - Please read instructions on reverse side before you begin this form.
I. EMPLOYEE ___________________________________________________EMPLOYEE ID NO.
____________________________
(6 digits)
STREET ADDRESS________________________________________________________________________________________________
CITY__________________________________________ STATE_____________________ ZIP CODE _____________________________
DEPARTMENT NAME_____________________________EMAIL ADDRESS_____________________________________________________
Do NOT complete shaded areas
II.
TYPE OF SERVICE
DATES OF SERVICE
Use one line to summarize all like expenses for eligible dependents with each daycare provider.
(Include: Month, Day, Year)
* No future dates *
Include names and dates of birth (DOB)
Daycare Provider
DOLLARS
CENTS
of dependents served (see example below)
SSN or TIN
Human Resources
Approval
XX
XX
Ex: 1/3/11-3/27/11
Example: Daycare for Susie (DOB 4/14/04)
555-22-3330
Employee Statement: The Undersigned under penalty of perjury states that the
TOTAL
above claim and the items as therein set out are true and correct and that the
amount therein is justly due. The Undersigned further certifies that the expenses
listed comply with the requirements and limitations of the Flexible Benefits
Program as listed on the back of this form.
NET AMOUNT
X
_______________________________________Date_____________________
EMPLOYEE: Please sign YOUR name here. Send claim with supporting
CLAIM #____________ CLAIM DATE________________ PLAN YEAR ___________
documentation to the Benefits Unit of Human Resources for approval. A check
will be sent to you in payment of this claim.
___________________________________________________________
HUMAN RESOURCES APPROVAL
Daycare Provider: The undersigned Daycare Provider states that the services provided and amount received are true and correct.
X__________________________________________________
Date____________________
TIN or SSN:__________________________
ACCOUNTING DATA FOR OFFICE USE ONLY - EMPLOYEE LEAVE BLANK
B S ACCT
INVOICE NUMBER
AMOUNT
7
0
2
D C
1
Scan & email claim form and supporting documentation to ,
forward via U.S. Mail to County of Ventura HR/Benefits, 800 South Victoria Ave., #1970 FSA, Ventura, CA 93009-1970, or Brown Mail to #1970 FSA
DCFSA Claim Form (rev 06-20-17).xls
PD-307 (Rev. 06-2017)
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