State of California
FLEXELECT REIMBURSEMENT CLAIM FORM
PLEASE READ THE INSTRUCTIONS ON THE BACK OF THIS FORM PRIOR TO COMPLETION.
PLEASE STAPLE SUPPORTING DOCUMENTATION TO THE BACK OF THIS FORM
SIGNATURE OF DAY CARE PROVIDER LISTED ABOVE: ______________________________________________________
Separate receipts are not required if your dependent care provider signs this form after you have completed and signed it. Separate receipts must be attached to this form if your dependent care provider does not sign this form.
A. NAME _____________________________________________________ HOME PHONE (
) _______________________________ DAY PHONE (
SOCIAL SECURITY NO. _______________________________________
B. MEDICAL REIMBURSEMENT ACCOUNT
SUMMARY OF EXPENSES
DATES SERVICE PROVIDED
Name of Person
Provider of Services
Amount to Be
to Employee (Ex.: Hospital, Doctor/Dentist, Drugstore, Medical Supply Store)
I understand, agree and certify to the following:
• I will use my Flexible Spending Account (FSA) to only pay for IRS-qualifi ed expenses, permitted under my Employer’s FSA plan(s), provided to me and my IRS-eligible dependents, on the date(s) indicated above as
being incurred within my period of coverage during the plan year.
• I will request reimbursement only after the services have been provided.
• I have not and will not seek reimbursement through any other source, and will exhaust all the other sources of reimbursement before seeking reimbursement from my FSA.
• I will collect and maintain suffi cient documentation to validate my reimbursed FSA expenses.
• I will not claim any reimbursed FSA expense for any federal income tax deduction or credit.
• I specifi cally release my Employer and FBMC from any liability resulting from either my participation in any FSA or for any misrepresentation I make regarding my requests for reimbursement.
• If I participate in my E