Fsa Dependent Care Claim Form printable pdf download

SUBMIT COMPLETED CLAIM TO:

BENEFITS ADMINISTRATION & INSURANCE SERVICES, LLC

ATTN: FSA CLAIMS ADMINISTRATION

11 Orchard Road, Suite 100, Lake Forest 92630

Phone: (949) 206-0272

FAX: (949) 206-0274

BENEFITS ADMINISTRATION & INSURANCE SEVICES, LLC

DEPENDENT CARE

FLEXIBLE SPENDING ACCOUNT CLAIM FORM

Employee's Name: ____________________________________________

Date: __________________

Address: _____________________________________________________________________________

Social Security Number: __________________________ Day Phone Number: _____________________

Employer: ____________________________________________________________________________

DIRECTIONS: This form is to be used to submit child and dependent care expenses for reimbursement

from your Dependent Care Flexible Spending Account. Attach itemized paid bills, receipts and

invoices for all expenses claimed. You should answer all questions on this form and sign at the

bottom.

I request reimbursement from my Dependent Care Flexible Spending Account for the

following expenses:

Name(s) of Dependent(s): __________________________________________________________________

Date Expenses Paid: _______________________________

Amount Submitted: $_________________

Period Covered: From _______/_______/_______

through

_______/_______/_______

Name and address of service provider:

___________________________________________________

Provider's Tax I. D. Number or Social Security Number: _______________________________________

READ CAREFULLY

I, the undersigned, certify that I am a participant in the Flexible Spending Account benefit plan and that all

expenses for which reimbursement or payment is being claimed by submission of this form were incurred

during a period of time during which I was covered under the Flexible Benefit Plan for such expense. I

fully understand that I alone am reponsible for the sufficiency and accuracy of all information relating to this

claim which is being submitted, and that unless an expense for which payment or reimbursement is claimed

is a proper expense under the Plan, I may be liable for payment of Federal, State and City income tax on

amounts paid from the Plan which relate to such expense.

Employee's Signature: _________________________________________

For Administrator Use Only

Administrator: ______________________________

Date Approved: ________________

Fsa Dependent Care Claim Form