Fsafeds Dependent Care Fsa Claim Form Page 3
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1
2
3USE THIS PAGE FOR ADDITIONAL DEPENDENT CARE EXPENSES.
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SECTION 4: EMPLOYEE INFORMATION (ABBREVIATED)
EMPLOYEE USEr ID (nO DASHES)
EMPLOYEE LAST nAME
EMPLOYEE FIrST nAME
SECTION 5: YOUR ADDITIONAL DEPENDENT CARE EXPENSES
EXPENSE 2
STArT DATE OF SErvICE (MMDDYY)
PrOvIDEr TAx ID Or SSn (EnTEr ALL 9’S IF TAx-ExEMPT)
AMOUnT rEqUESTED (DOLLArS . CEnTS)
.
$
EnD DATE OF SErvICE (MMDDYY)
DEPEnDEnT DATE OF BIrTH (MMDDYYYY)
ExPEnSE 2 COvErS:
DEPEnDEnT nAME
EXPENSE 3
STArT DATE OF SErvICE (MMDDYY)
PrOvIDEr TAx ID Or SSn (EnTEr ALL 9’S IF TAx-ExEMPT)
AMOUnT rEqUESTED (DOLLArS . CEnTS)
.
$
EnD DATE OF SErvICE (MMDDYY)
DEPEnDEnT DATE OF BIrTH (MMDDYYYY)
ExPEnSE 3 COvErS:
DEPEnDEnT nAME
AFFIDAvIT:
Your daycare provider only needs to sign this if you do not have supporting documentation, such as an itemized receipt.
I hereby certify that I provided adult or child daycare services to the above individuals in accordance with the amounts and dates that
are requested.
PrOvIDEr’S SIGnATUrE
DATE
USE An OrIGInAL FOrM (nOT A PHOTOCOPY)
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Page 3 - DEPENDENT CARE CLAIM FORM
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