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Take full responsibility for the accuracy of all information I have provided. I further understand that reimbursed expenses cannot be claimed as a credit on my personal income tax return. Employee Signature: Date: We want to promptly process your claim. Please complete all appropriate sections as the claim form will be returned to you if incomplete. Please keep a copy of this claim form for your records. Submit Completed Form and attachments to: MidAmerica Administrative & Retirement Solution.

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