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SING BRANCH P.O. BOX 419205 KANSAS CITY, MISSOURI 64141-6205 5. LICENSE NO. ! 3. ORDER NO. 4. DESCRIPTION: (Check one) PAPER RECEIPTS PUNCHED CARDS 6. PRINT AND/OR PREPUNCH: RECEIPT NUMBERS CCC WAREHOUSE CODE NO. 7. NAME OF WAREHOUSE 8. LOCATION OF WAREHOUSE 9. NAME OF WAREHOUSEMAN 10. INCORPORATED UNDER THE LAWS OF STATE OF: 11. CHECK ONE (If not incorporated, show "None.") PROPRIETOR LESSEE 13. SERIALLY NUMBERED 12. QUANTITY WANTED FROM NEITHER 14. COPIES IN SET (Excluding.

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They may put a temporary hold on your debit card or request repayment until you can locate and produce appropriate documentation. Or your employer may report unsubstantiated amounts as taxable income on your form W-2.

The IRS requires that every dollar spent from an FSA be eligible and verified. This verification process is "substantiation".

How can I use my FSA money? You can use the funds from your FSA either with an FSA debit card provided by your employer, or by submitting paper receipts for reimbursement of FSA eligible expenses.

While FSA funds are deducted by the employer during payroll, the benefits vendor administering the FSA is responsible for verifying the receipts rather than the employee.

Yes. You can find a list of past orders in Your Orders. Contact your plan administrator or employer for more information on what items are eligible and how to provide appropriate documentation for reimbursement.

Required Documentation: Itemized statement from the provider with a clear description of service provided, name of the patient, date of service, the amount paid for service, and name of the provider. A signed statement indicating there is no insurance coverage for the service provided.

An itemized receipt with the five pieces of information is compliant. They need the date(s) of service, dependent's name, provider's name, type of service, and the total dollar amount paid for the services.

Submit Your Claim in One of These Ways Once you have logged into your account, click Submit Receipt or Claim and select your Reimbursement Option. Follow the step-by-step instructions. Upload digital copies of your itemized receipts (and other documentation if needed).

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232