P & A Administrative Services, Inc. Today’s
Date: ________________
Flexible Spending Account Claim Form #
of pages: ___________
DEBIT CARD DOCUMENTATION
RESUBMISSION This claim is for
the plan year beginning July 1, 2008
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Employer
Name: TOWN OF |
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Employee
Name: |
Employee
Mailing Address: |
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Last
4 digits of Social Security Number: |
City,
State, Zip: |
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E-mail
Address: |
Daytime
Phone Number: |
Medical Expense Reimbursement Account Total
Amount Requested______________
Dependent Care Reimbursement Account Total
Amount Requested______________
Date of
Service
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Employee,
Spouse or Dependent |
Amount
Requested |
Type
of Service |
Service
Provider or RX # |
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1. |
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2. |
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3. |
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4. |
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5. |
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1.
Enclose insurance company statement or itemized bill from provider showing
date of service, services rendered, provider of service, amount paid and, if
applicable, amount covered by insurance.
2.
Please number each item according to its order of appearance on this
form.
3.
IRS guidelines do NOT consider cancelled checks as valid
documentation.
4.
Previous balances are NOT acceptable.
5.
Complete all information on claim form including signature and date.
6.
All reimbursements will be made payable to the employee.
I certify that these expenses for which
reimbursement is claimed from the Flexible Spending Accounts have been incurred
by me and/or my eligible dependents and are not, and will not, be payable by
any other plan and will not be deducted on my federal, state or local income
tax returns. (Claim forms not signed
will not be processed.)
EMPLOYEE’S
SIGNATURE_____________________________________________________DATE________________
For faster service, fax claims to:
1-877-855-7105 (toll free)
Or
mail to: Flex Department, P&A Administrative
Services, Inc., 17 Court Street,