Dependent Care Fsa Claim Form
Download a blank fillable Dependent Care Fsa Claim Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dependent Care Fsa Claim Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2D
e
p
e
n
d
e
n
t
C
a
r
e
/
E
l
d
e
r
C
a
r
e
D
e
p
e
n
d
e
n
t
C
a
r
e
/
E
l
d
e
r
C
a
r
e
S
p
e
n
d
i
n
g
A
c
c
o
u
n
t
S
p
e
n
d
i
n
g
A
c
c
o
u
n
t
C
C
l
l
a
a
i
i
m
m
F
F
o
o
r
r
m
m
Employee Information
Employer Name
Name
Date of Birth
Employee ID Number
City
State
Zip Code
Street Address ( New Address)
Contact Information (Phone or Email)
Dependent Care Expenses (See reverse side for instructions)
Dependent
Date of
Relation
Provider of Service
Provider’s Tax
Service Dates
Amount of
Suffix
Name
Birth
ID
From
To
Expense
(office
use)
$
$
$
$
$
Provider must complete the below portion if you are not attaching an
TOTAL
$
Itemized bill as proper documentation. Photocopies of claim forms
0.00
will not be accepted as proper documentation
Date(s) of Service Rendered:
T
o
t
a
l
A
m
o
u
n
t
B
i
l
l
e
d
:
SSN or Tax I.D. #
T
o
t
a
l
A
m
o
u
n
t
B
i
l
l
e
d
:
From:
To:
$
P
r
o
v
i
d
e
r
’
s
A
d
d
r
e
s
s
PROVIDER SIGNATURE:
P
r
o
v
i
d
e
r
’
s
A
d
d
r
e
s
s
Total Expenses:
0.00
Authorization
To the best of my knowledge and belief, my statements in this request for reimbursement are complete and true. I am
claiming reimbursement only for eligible expenses incurred during the applicable plan year for my legal dependent(s).
Please note that domestic partners and their children are not eligible unless they are also legal dependents. I certify that
these expenses have not previously been reimbursed, nor will they be reimbursed under any other benefit plan and will
not be claimed as an income tax deduction. If there is a discrepancy between the total amount of expenses requested
above and the total amount of the attached receipts, I will be reimbursed according to the total amount of eligible
expenses on the attached receipts.
Signature: _______________________________________________________
Date: ______________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal