FLEXIBLE
SPENDING REIMBURSEMENT
CLAIM FORM
EMPLOYEE NAME: __________________________________________________________
SOCIAL SECURITY #: ______________________________ PHONE EXT: _________
Attach Proof of Incurred Expense: Insurance company’s. Explanation of Benefits (EOB), day care receipts with dates of service, etc.).
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Date of Service |
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Expense for: Family Member |
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Provider:
Doctor, Day Care Facility, etc. |
Amount
of Expense
Medical Dependent Care
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$ |
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$ |
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$ |
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$ |
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$ |
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TOTALS
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$ |
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$ |
I affirm that the above request for reimbursement are expenses recognized by the Internal Revenue Code as tax deductible expenses under Section 125 “Cafeteria Plans” and assume all responsibility for taxes or penalties arising out of any disallowed deductions.
EMPLOYEE SIGNATURE _________________________________ DATE ____________