Flexible Spending Account Claim Form Instructions

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Flexible Spending Account Claim Form Instructions Powered By Docstoc
					Employer Name:                                                                                                       Claim Reimbursement Form
Participant Name:                                                                                           Social Security Number:
                                                                           Daycare Expense Claim Information
       Name of                          Dates of Service                              Name, Address and Taxpayer Identification Number
                                                                                                                                                                                          Cost of Daycare
      Dependent                        From           To                                            of Daycare Provider




                                                                                                                                                                     * Total                       $0.00
*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 earning of $200 if there is one [1] child or dependent, and $100 if there are two [2] or more.) No payment may be
made under the Plan if the service provider is your dependent for federal income tax purposes, or is your child or stepchild and is under age 19.


                                              Unreimbursed Medical Expense Claims (Flexible Spending Account)
                                                                                                                                                   Person For Whom                         Reimbursement
 Date of Service                Name of Service Provider                                      Service Description
                                                                                                                                                 Service Was Incurred                         Amount




                                                                                                                                                                        Total                     $0.00

IMPORTANT: Valid Service Receipt(s) MUST be included with your claim reimbursement form. Valid Service Receipts must contain the
following to be processed: Patient Name, Provider Information, Date Service Was Incurred (Rx Fill Date), Procedure Performed (Office Visit) or Rx
Drug Name, and Cost. Over-the-Counter medication receipts will not include Patient Names. Attach and itemize additional medical claims on a
separate sheet, if necessary. Please see our Claim Filing Instructions document for more information.

                                   #####################################################################################################




Participant Signature:

                             Date:                                                                                                              4740 Peach Street / Erie, PA 16509
                                                                                                                                         Local: 814-866-9400 / Toll-Free: 800-494-6804
                                                                                                                                                      Fax: 814-868-7556
                                                                                                                                                         www.eBeneAdmin.com
             Rev: 12/2005

				
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