Dependent Care/ Health Care Reimbursement Account Plans Claim Form

NAME: (Please Print)

Campus

Social Security Number

Street Address

City, State, Zip

Telephone Number

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

Age

Date(s) Care

Provided

Name, Address, and Taxpayer Identification Number of Care

Provider

Cost for Care Period

ASIFlex use

only

From To*

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

Provided

(Arrange

documentation in same

order)

Name of Medical

Provider

General Medical Expense

Description. Include medical condition for

over-the-counter items.

Patient Name Relationship

Amount that is

your

responsibility

ASIFlex

use only

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.

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