Fillable Fsa Claim Form - Flex Made Easy printable pdf download

Clear Form

FSA Claim Form

Your Name (Last, First, MI)

Social Security No. or EID

Your Employer Name

Address

City

State

Zip Code

Dependent Care Flexible Spending Account Claims

Payment is allowed only for services that have already been provided and not for services to be provided in the future. To substantiate your

claim, submit an itemized statement from your provider or simply have your provider(s) sign below to certify* the care was provided. If

your provider signs below, no other supporting documentation is required.

Dates Care Was

① Name/Address of Care Provider or Care Facility

Provided

Name of

Amount

Age

② Type of Dependent Care Service

No Future Dates

Dependent

Requested

(Daycare, Day Camp, Preschool, After School Care, etc.)

MM/DD/YY thru

MM/DD/YY

①

②

①

②

①

②

Total

0.00

* Day Care Provider or Care Facility Certification:

I certify that I provided dependent care services as detailed above.

Print Name: ___________________________________________________

Print Name: ______________________________________________________________

Original Signature: ______________________________________________

__________________________________________________

Original Signature:

Date: ________________________________________________________

___________________________________________________________

Date:

Health Care Flexible Spending Account Claims

Please submit a detailed billing statement or your insurance carrier’s Explanation of Benefits (EOB) statement. Paid receipts are not sufficient

documentation.

Date(s) of

Relationship

Amount

Type of Expense

Health Care Provider

Patient Name

Service

to You

Requested

(Office Visit, Crown, Eyeglasses, Rx, etc.)

Total

0.00

I certify that all expenses for which reimbursement or payment is claimed by submission of this form were incurred by me, an eligible spouse, or an eligible

dependent during a period while I was covered under my employer's FSA Plan and that the expenses have not been reimbursed and reimbursement will not be

sought from any other source. Any claimed Dependent Care expenses are work-related and were provided for my dependent under the age of 13 or for my

dependent who is incapable of self care. I understand that I am fully responsible for the accuracy of all information relating to this claim, and that unless an

expense for which reimbursement is claimed is a proper expense under the Plan, I may be liable for payment of all related taxes including federal, state, or local

income tax on amounts paid from the Plan which relate to such expense. A claim will only be processed with a completed and signed claim form and correct

documentation.

Employee Signature ___________________________________________________________

Date __________________________________

Fax to:

1-816-841-3790

Mail to:

Flex Made Easy

File Online:

Page 1 of

410 Archibald St, #100

NO CLAIM FORM NEEDED!

NO COVER PAGE REQUIRED