2011 VALENCIA COLLEGE FLEXIBLE BENEFITS
Flexible Spending Account Reimbursement Claim Form Employee Name: Mail Code:
Employee VID Number: Campus Ext:
Please read the attached instructions carefully. Incomplete claim forms or claim forms missing required documentation will not be processed. Claims received after the Payroll deadline will be processed on the following paycheck.
EMPLOYEE/DEPENDENT HEALTH CARE EXPENSES (List dates of service separately; attach additional sheet(s) as needed) TYPE OF EXPENSE
SERVICE DATES From To
NAME OF PATIENT\RELATIONSHIP
PROVIDER OF SERVICE
AMOUNT REQUESTED
TOTAL HEALTH CARE AMOUNT REQUESTED:
DEPENDENT CARE EXPENSES (not for dependent medical expenses) PERIOD OF DEPENDENT CARE
NAME OF DEPENDENT AND RELATIONSHIP
DEPENDENT CARE PROVIDER
AMOUNT REQUESTED
TOTAL DEPENDENT CARE AMOUNT REQUESTED: I certify that I have actually incurred these expenses and I have not previously been reimbursed for them. I understand that any amounts reimbursed cannot be claimed on my spouse's and/or my personal income tax for the purpose of income or tax reduction. Where applicable, the above health care claims have been processed by any applicable coverage and the documentation is attached. No other insurance has paid or is responsible for this/these claims. I further understand that any amounts remaining at the end of the year that cannot be claimed will be forfeited.
(Initial)
DEPENDENT WITH NO INSURANCE ATTESTATION: Initial line and check the box only if applicable: I certify that the patient/dependent, listed above, does not have any insurance coverage responsible for payment of this claim; therefore, I have attached itemized medical receipts instead of Explanation of Benefits from an insurance company.
Signature
Date ________________________________
HUMAN RESOURCES USE ONLY Amt to reimb:
MED:
DEP:
PAYROLL USE ONLY Date reimbursed:
Signature:
Signature:
Date:
Date: HR Form #36 Revised 07/11