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For N2 e2464 <br />FLOUBLE SPENDING ACCOUNT REIMBURSEMENT REQUEST FORM <br />Company <br />Employee <br />Employee Name <br />Cr ,.iele the Information below for expenses incurred by you, your spouse or other <br />eligible dependents and for which you request reSmbursemont. When dates are <br />requested: please show them as month/day/year. Exampia: 06/15/87 <br />nv rw <br />rat <br />SS# <br />State — Zip <br />as sure to provide all information requested by this form. If the form Is incomplete, <br />it will be returned to you. Print or typo the information requested. Then dale and <br />sign the form. Keep the pink copy for your m.n records. Send the white copy <br />to: DCA, Inc. <br />Atleniion: FlexComp Department <br />13100 Wayzata Bou!evard <br />Minnetonka, MN 55343 <br />(4) (5) (6) (7) (8) (0) <br />Lino <br />Dales ofSmlu <br />I Provider of Service <br />(Name of doctor, dentist, <br />Person re.dving service <br />(self, spouse, dependents) <br />I Total Expense <br />Amount Paid <br />Eye <br />Amount Paid <br />By <br />Expanss Typo <br />(checkoni) <br />Fo.0e <br />Use <br />day cars provider, <br />I <br />Plans <br />aou/spuuss <br />Medical Day <br />1 <br />d ugolst, etc.) <br />Dental cafe <br />2 <br />J <br />I <br />a <br />— <br />6 <br />_ <br />7 <br />a <br />�_------ <br />10 <br />---I <br />— <br />11 <br />f <br />IMPORTANT: Check your lolels. Colun.n(6) <br />a -Note: This is your <br />Totals: E $ requested amuvnt <br />+ column (7) should equal column (5). <br />I request payment from my health care expense or day care expense reimbursement account as indicated abov t for the expenses listed in column (7). 1 certify that these expensesr <br />have been paid, are not eligible for further reimbursement under any other plan, and comply with the requirements listed on the back of this to, I have not and will not claim <br />these expe9; es for tax credit or deduction purposes on my income tax return. <br />® S:gned Date_'_ <br />125/129 NO REC CL FORM 12�87 <br />