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FSA Reimbursement Request

FSA Reimbursement Request

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    • 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 Account Plan and that the expenses have not been and or will not be sought for reimbursement 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 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. I am responsible for any inappropriate use or disclosure of my information that occurs due to my selected method of transmitting this information (e.g., fax, e-mail, or any other media). I will include the Social Security Number of any Dependent Care service provider(s) listed above on my annual tax return(s). I authorize the Plan and its service provider, their respective agents, employees, subcontractors, and assigns to use and/or disclose the information provided above as they reasonably deem necessary to manage the Plan (including but not limited to, disclosures to my employer for Plan administration purposes, such as the evaluation of eligibility for reimbursement under the Plan) and to detect or prevent fraud or misrepresentation. I give up any claims related to the use, disclosure, or release of this information so long as the information is used for the purposes defined above.
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