Fsa Reimbursement Request Form - Asi printable pdf download

FSA

Reimbursement Request Form

Employer

Employee Day Time Phone #

Employee Last Name

First Name

Employee SS#

□

⁯

City

State

Zip Code

Employee Street Address

Check this box if new mailing address

Expenses Incurred by

Relationship to Employee

ITEMS REQUIRED WHEN SUBMITING THIS FORM:

(1) Complete all pertinent information in the spaces provided, sign, date & return to ASI. Our contact information is below.

(2) Attach an itemized statement or receipt to support requested reimbursement(s).

(3) Your statement or receipt MUST include: Date of Service, Description of Expense & Amount of Expense.

# must be clearly listed for approval.

Provider’s Tax ID# or Certification

DATE OF EXPENSE:

EXPENSE TYPE:

REQUESTED AMOUNT:

⁮ UNREIMBURSED / MEDICAL RELATED

Month/ Date/ Year

SUBTOTAL OF MEDICAL RELATED EXPENSE

⁮ DEPENDANT DAY CARE

Month/ Date/ Year

SUBTOTAL OF DEPENDANT DAY CARE REQUESTED

Dependant Day Care: Complete this section in lieu of statement or receipt for Dependant Care.

Provider’s ID#:

Provider’s Address:

DEPENDANT NAME:

DATE OF SERVICES:

AMOUNT BILLED OR RECEIVED:

_________________________________

____________________________________

_______________________________

_________________________________

____________________________________

_______________________________

_________________________________

____________________________________

_______________________________

______________________________________

__________________________________________

____________________________________

Dependant Care Provider Name

Signature of Provider

Signature Date

The undersigned participant in the Plan certifies that all expenses, for which reimbursement or payment is claimed by submission of this form, were incurred during

a period while the undersigned was covered under the Plan with respect to such expenses; and that such expenses have not been reimbursed, or are not reimbursable,

under any other benefit plan coverage. The undersigned fully understands that he or she alone is responsible for the sufficiency, accuracy, and authenticity 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 the payment of all related taxes including federal, state, or city income tax on amounts paid from the Plan

which relate to such expense.

______________________________________________________

_________________________

Plan Participant’s Signature

Signature Date

P.O. Box 5809, Fresno CA 93755 / 555 W. Shaw Ave., Ste C-1, Fresno CA 93704

Phone: (559) 256-1320 Fax: (559) 475-5782 Toll Free: (866) 777-1320 Email: