2010 Flexible Spending Account (Fsa) Dependent Care Reimbursement Form
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1
2Aetna Inc.
Flexible Spending Account (FSA)
P O Box 4000
1 B
Dependent Care Reimbursement
R ichmond, KY 40476-4000
0 B
Fax to: 1-888-238-3539 (1-888-AET-FLEX)
For the hearing impaired, call 1-877-703-5572 TDD/TTY
•
T o avoid claim payment delay, you must complete all sections (including, if applicable, Section 4) and sign and date this form
.
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U
•
If attaching a receipt from a dependent care provider, the receipt must include the following information: (1) name and address of
caregiver; (2) name of qualifying person; (3) dates of service; (4) amount charged; and (5) type of service.
N ote
: If the caregiver
U
U
signs the Caregiver Certification below, no receipt or additional documentation is required.
•
Refer to Instructions on reverse side.
1. Employee Information
Employee’s FSA Identification Number
Employee’s Last Name
First
MI
Daytime Telephone Number
W
(
)
Street Address
City
State
Zip Code
2. Employer Information
Employer Name
FSA Control Number
3. Dependent Care Expense Information
Qualifying Person’s First Name
Date of Birth (MM/DD/YYYY
)
Relationship to Employee
Spouse
Child
Other
/
/
U
U
Qualifying person is over age 12 and is mentally or physically incapable of self-care due to a diagnosed medical condition.*
Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
U
U
U
U
U
Qualifying Person’s First Name
Date of Birth (MM/DD/YYYY
)
Relationship to Employee
Spouse
Child
Other
/
/
U
U
Qualifying person is over age 12 and is mentally or physically incapable of self-care due to a diagnosed medical condition.*
*Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
U
U
U
U
U
Qualifying Person’s First Name
Date of Birth (MM/DD/YYYY
)
Relationship to Employee
Spouse
Child
Other
/
/
U
U
Qualifying person is over age 12 and is mentally or physically incapable of self-care due to a diagnosed medical condition.*
*Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
U
U
U
U
U
4. Expenses for Before & After Kindergarten
Qualifying Person’s First Name
Date of Birth (MM/DD/YYYY
)
Relationship to Employee
Spouse
Child
Other
/
/
U
U
Date(s) of Service (MM/DD/YYYY)
From
/
/
Thru
/
/
Total Amount Submitted $
U
U
U
U
U
* You do not need to submit evidence of diagnosed medical condition.
5. Caregiver Information
Caregiver Name
Social Security Number or Tax ID Number of Caregiver
Relative
Yes
No
Address of Caregiver
Telephone Number of Caregiver
(
)
6. Employee and Caregiver Certifications - Review instructions on page two.
EMPLOYEE: I certify that all the expenses listed above for which I am seeking reimbursement from the Flexible Spending Account have been
incurred. I further certify that these expenses have not been reimbursed, nor shall I seek reimbursement, from any other dependent care assistance
program. I also certify that I have not, and will not, claim a tax deduction or credit for these expenses on my federal income tax return, nor will I claim a
tax deduction or credit for these expenses on my state or local tax returns in violation of state or local law. I further certify that the above dependent
care expenses are for the care of a Qualifying Person and do not include separate charges for food, clothing, education, entertainment, activities, late
fees, or overnight care. I agree to submit and retain sufficient documentation for any expense for which I seek reimbursement.
Any person who knowingly and with intent to defraud files a statement of claim containing any materially false, incomplete or misleading information is
guilty of a crime.
Sign Here ►Signature of Employee
Date
CAREGIVER: I certify that the services for which expenses are claimed above have actually been provided.
Any person who knowingly and with intent to defraud files a statement of claim containing any materially false, incomplete or misleading information is
guilty of a crime.
Sign Here ►Signature of Caregiver
Date
GC-12 (8-10) H
R-POD
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