Reimbursement Request Form Mdea, Dcea & Hra (Rev. 12/2015)
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1
2
3STATE OF MINNESOTA
R
R
F
EIMBURSEMENT
EQUEST
ORM
MDEA, DCEA & HRA
Benefit Year: _2016______________ State Employee ID Number: ___________________________
First Name: __________________ MI: _____ Last Name: _______________________________
Address: _______________________________ City: _____________State: ____ZIP: _________
Daytime Phone: (_____)_____________ Email: _______________________________________
Please verify that the mailing address above is current with the State. Address changes cannot be accepted via
reimbursement forms.
Complete the information below for expenses incurred by you, your spouse, or other eligible dependents for which you request payment. See reverse side for
complete instructions. If the form is incomplete it will be returned to you and your reimbursement will be delayed. Print or type the
information requested, then date and sign the form. Keep a copy of all documentation for your records. There is a $50.00 minimum reimbursement
amount except for claims filed after the last week of the plan year.
Unreimbursed Medical/Dental Expense (for you, your spouse and your dependents)
Date(s) of
Person for
Expense
Name of Service
Net
Service
Whom Expense
Amount*
Description
Provider
(MM/DD/YY)
Incurred
1.
2.
3.
4.
5.
6.
7.
Total Unreimbursed Medical/Dental Expense
$
Note: If you need additional space, attach a separate sheet
of paper.
Claimed
*Net Amount is the amount of the claim not reimbursed to you through another plan: for example, through health or dental insurance.
Unreimbursed Dependent Care Expense (Daycare Expenses)
Identify below the Provider Name, Tax
OR
ID and Signature
attach a receipt
Actual
Period Covered
Name of
from the Provider with the Provider
Amount
from (MM/DD/YY) to
Dependent
Name, Tax ID and Signature. The
Incurred
(MM/DD/YY)
information is required with each
submission.
8.
Provider Signature -
9.
Provider Signature -
Total Unreimbursed Dependent Care Expense
$
Claimed
Note: If same Dependent Care Provider for each claim listed above, signature is required only once.
Read Carefully
I certify that all expenses, for which reimbursement is claimed on this form, were incurred during a period while I was covered
under the cafeteria plan for the State of Minnesota. I fully understand that I alone will be responsible for the sufficiency, accuracy,
and veracity of all information relating to this claim which I am submitting. If an expense for which I am claiming reimbursement is an
improper expense under the plan, I 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.
* Do not include MDEA or HRA reimbursement requests that have been paid through your MDEA/HRA debit card.
EMPLOYEE PLEASE SIGN HERE
DATE
Plan Year January 1, 2016 through December 31, 2016
Final deadline for claims is February 28, 2017.
121
Benefits
Send or fax this form with documentation to:
730 2nd Ave. S., Ste. 400
Fax: 612-877-4322
730 Building
Rev. 12/2015
Minneapolis, MN 55402-2466
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