Flexible Benefit Plan Employer Employee Phone Dependent Care Expense by daylah


									Flexible Benefit Plan                                                                                 Reimbursement Claim Form
                                                                                                                                               Page ___ of ___
Employee:                                                                                  Social Security Number
Phone:                                                                                     E-mail address:
Dependent Care Expense Claims
       Name of Dependent(s)                  Date of         Period Covered             Name, Address and Taxpayer Identification or
                                                                                         Social Security Number of Service Provider                   Amount Incurred
                                              Birth         From            To




                                                                                       TOTAL DEPENDENT CARE EXPENSES INCURRED                         $
* Attach a receipt from your daycare provider or include the daycare
provider’s signature
                                                                                                                       Provider’s 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. Care must be for a “Qualifying Individual” as defined by the IRS. No payment may be made
under the Plan if – (a) service provider is your dependent for federal income tax purposes or (b) is your child or stepchild and is under age 19.

Unreimbursed Healthcare Expense Claims
                                                       Medical Expense Description
 Date Expense                                                                                                                                                  Your
                           Name of Service               (copay etc) and medical
   Incurred                                                                                                                          Relationship          Responsibility
                             Provider                    condition for Over-The-                        Patient Name
   (mm/dd/yy)                                                                                                                                                Amount
                                                       Counter items (headache etc).
* Attach receipt(s) and submit with this claim
                                                                                                         TOTAL EXPENSES             $
↑ Please arrange documentation in order listed above. Reimbursement requests for future services will not be accepted.
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 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. Dependent Care
Assistance expenses claimed here were provided for my dependent under the age of 13 or for a dependent who is incapable of self care.

I certify that these expenses have not been reimbursed and I will not seek reimbursement for them under a major medical plan or any other health plan,
such as an individual policy or my spouse’s or dependent’s health plan. I understand that the expense for which I am reimbursed may not be used to
claim any federal income tax deduction or credit.

__________________________________________________________________                                    ______________________________________________
Employee’s Signature                                                                                            Date

Mail or fax your claim form and receipts to:
SOUTHWEST BENEFIT ADMINISTRATORS, LLC                                                      Additional claim forms and account balance information
ATTENTION: FLEX CLAIMS                                                                     can be obtained at: www.myflexonline.com
FAX:     602.588.3984
                                                   Flexible Benefit Plan
                                               Claim Form & Filing Instructions
                           On the reverse side of this page is a claim form. Please feel free to copy this form.

For the fastest service, did you remember to include:
Receipts in order listed on the reimbursement?        Include the TAX ID or SS# of the daycare provider?
Claim form is signed and dated?                       Retained original claim form and supporting documents?

Your account balance as well as valuable information regarding flexible spending is available at

When filing your claim, you must attach copies of the receipts pursuant to IRS substantiation rules . The receipt must show the date
and type of service for the expense. Canceled checks, credit card slips, or statements showing only a balance due on your account are
not allowable. Please be sure to number each attachment page (i.e. Page 2 of 3, Page 3 of 3, etc.).

If you choose to mail your claim with receipts the address is:

                                        SOUTHWEST BENEFIT ADMINISTRATORS, LLC
                                              ATTENTION: FLEX CLAIMS
                                                 5656 W TALAVI BLVD
                                              GLENDALE, ARIZONA 85306

           Please be sure to keep the original claim form and supporting documents (i.e. receipts) for your records.

If you choose to fax your claim with receipts, the fax number is: ATTENTION: FLEX CLAIMS 602.588.3984

After you have submitted your claims via fax, please do not follow up with a hard copy in the mail.

To verify your claim has been received, go the website described below. When your claim is approved, it will appear within three
business days on the website under “View Account” (account registration and login is required to view personal account

You may check your account balance status at any time, day or night at the website. In addition, the website has a claim form, a list of
qualifying expenses and other administrative tools that will help you conveniently manage your account. The site also has frequently
asked questions and instructions on how to contact us. The website address is www.myflexonline.com.

                                             ...everything you need to manage
                                             your Flexible Benefit Account…
                             →    Verify your election                 →     Change in status rules
                             →    View your account balance            →     Eligibility requirements
                             →    Print claim forms                    →     Learn about the plan
                             →    How and where to file claims         →     How to contact us
                             →    Look up qualified expenses

                                         Copy the front and back of the claim form for future use

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