ANDERSON UNIVERSITY

FLEXIBLE SPENDING REIMBURSEMENT

CLAIM FORM

 

 

EMPLOYEE NAME: __________________________________________________________

 

SOCIAL SECURITY #:        ______________________________ PHONE EXT:  _________

 

 

Attach Proof of Incurred Expense:  Insurance company’s. Explanation of Benefits (EOB), day care receipts with dates of service, etc.).

 

Date of Service

 

Expense for:  Family Member

 

Provider:  Doctor, Day Care Facility, etc.

Amount of Expense

 

          Medical               Dependent Care

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

$

 

$

 

 

 

 

TOTALS

 

$

 

$

 

 

I affirm that the above request for reimbursement are expenses recognized by the Internal Revenue Code as tax deductible expenses under Section 125 “Cafeteria Plans” and assume all responsibility for taxes or penalties arising out of any disallowed deductions.

 

EMPLOYEE SIGNATURE _________________________________          DATE ____________