Flexible Spending Account Claim Form Dependent Care printable pdf download

Flexible Spending Account Claim Form Dependent Care

Flexible Spending Account

Claim Form ~ Dependent Care

OSR 5-344 (Rev 1-4-2010)

Employee’s Name ______________________________________________________

Social Security Number ________________-___________- _____________________

Employee’s Daytime Phone (__________) __________________________________

Please refer to the instructions on the back of this form to ensure you attach all required documents.

Dependent’s Name

Sex Birthdate

Provider Information

Dependent Care Provider Name _______________________

Address ___________________________________________

Provider Federal Tax ID# or SSN _______________________

Dates of Services: From ____________ To _____________

Amount Requested: $ ________________________________

Dependent Care Provider Name _______________________

Address ___________________________________________

Provider Federal Tax ID# or SSN _______________________

Dates of Services: From ____________ To _____________

Amount Requested: $ ________________________________

Dependent Care Provider Name _______________________

Address ___________________________________________

Provider Federal Tax ID# or SSN _______________________

Dates of Services: From ____________ To _____________

Amount Requested: $ ________________________________

Dependent Care Provider Name _______________________

Address ___________________________________________

Provider Federal Tax ID# or SSN _______________________

Dates of Services: From ____________ To _____________

Amount Requested: $ ________________________________

EMPLOYEE CERTIFICATION

I authorize my Flexible Spending Account (FSA) to be reduced by the amount of expenses listed above.

The expenses incurred by myself or my eligible dependents are not reimbursable from any other source.

I understand that these expenses cannot be claimed as credits or deductions on my income tax return.

I further certify that I have read and understand the information outlined on the back of this form. The

information on this form is true and correct to the best of my knowledge.

Employee’s Signature _______________________________________

Date ___________________

Flexible Spending Account Claim Form Dependent Care