Fillable Fsa Reimbursement Claim Form printable pdf download

Fsa Reimbursement Claim Form

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Reimbursement Claim Form

Your Flexible Benefit Plan

Employer

Page

Employee Name

Social Security #

Phone

E-mail

Dependent Care Expense Claims

Name, Address, and Taxpayer Identification Number of

Period Covered

Name of Dependent(s)

Amount Incurred

Provider Service

From

Attach a receipt from your day-care provider,

Provider's

or include the day-care provider's signature.

Total Dependent Care Expense Claim*

$0.00

Signature:

*NOTE: The total amount claimed under the Plan for any coverage period must not exceed the lesser of your earned income for the Plan Year or the earned income

of your spouse. (If your spouse is either a full-time student or is incapable of taking care of himself or herself, then he or she is deemed to have monthly earnings of

$250 if there is one (1) child or dependent, or $500 if there are two (2) or more.) No payment may be made under the Plan; if the service provider is your dependent

for federal income tax purposes; or is your child or stepchild and is under age 19. Please visit

for more details.

Unreimbursed Medical Expense Claims for FSA and/or HRA accounts

FSA

Date Expense

Person for Whom

Card

Expense Description -

FSA (unless checked)

Name of Service Provider

Net Amount

Receipt

Incurred

Expense Incurred

HRA

Total Medical Care Expense Claim

$0.00

Attach appropriate receipt(s) and submit with this claim form.

Read Carefully:

The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were provided during a

period while the undersigned was covered under the Company's Cafeteria Plan with respect to such expenses and that the medical expenses have not been

reimbursed or are not reimbursable under any other health plan coverage. The undersigned fully understands that he or she alone is fully 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 or

reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes including federal, state, or city income

tax on amounts paid from the Plan which relate to such expense.

Signature area:__________________________________________________________

Date/Time Field

More Claim Forms - Check your account balance at

301-977-5660

Print and Fax

>>> Claim & Receipts to

Attention: 125Company Flex Claims Group

Phone: 301-977-8840