NAME: (Please Print)
Social Security Number
City, State, Zip
Dependent Care Reimbursement Account (DCRA)
Dependent care expenses must be for a dependent who is incapable of self care or under the age of 13 at the time the care was provided.
Name of Dependent
Name, Address, and Taxpayer Identification Number of Care
Cost for Care Period
Total Dependent Care Amount Requested
I provided the dependent care as stated above. __________________________________________ __________ _______________
Care Provider's original signature Date SSAN/Tax ID#
*Claims for future services are not eligible for reimbursement.
Health Care Reimbursement Account (HCRA)
Date Medical Care
documentation in same
Name of Medical
General Medical Expense
Description. Include medical condition for
Patient Name Relationship
Amount that is
Total Medical Amount Requested
Please submit a DETAILED STATEMENT OF SERVICES or INSURANCE EXPLANATION OF BENEFITS (EOB) statement for each expense you are claiming.
Credit card receipts or statements with a previous balance are not sufficient documentation.
As a participant of the Plan, I certify that all expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while I
was covered under my employer's Flexible Spending Plan and that the expenses have not been reimbursed and reimbursement will not be sought from any other source.
Any claimed Dependent Care Assistance expenses were provided for my dependent under the age of 13 or for my dependent who is incapable of self care. I fully
understand that I am fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim, and that unless an expense for which payment or
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.
Employee's Signature Date
ASIFlex Submit Form to ASIFlex ALONG WITH
P. O. BOX 6044 SUPPORTING DOCUMENTATION
COLUMBIA MO 65205-6044
Toll-free fax (877) 879-9038
Web site: http://www.asiflex.com Online Claims Submission https://my.asiflex.com
*No Cover Page Required*
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Dependent Care/ Health Care Reimbursement Account Plans
CLAIM FORM – PLAN YEAR 201__