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E Spending Account Plan Lifestyles Spending Account Claim Form 1. Your Information (please print) First Name: Last Name: Address: Benefit ID: City: Date of Birth: (dd/mm/yyyy) Province: Postal Code: Home Telephone Number: Work Email: Work Telephone Number: Employer Name: 2. Claim Details DATE OF EXPENSE (dd/mm/yyyy) TYPE OF EXPENSE # OF RECEIPTS AMOUNT CLAIMED APPROVED AMOUNT (for 3sHealth use only) $ $ $ $ $ $ $ $ TOTALS $ $ $ $ INSTRUCTIONS: Attach all bills and rec.

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