Get Universal Receipt Form
Lan Year: Name of Provider Mail a Check Direct Deposit Current Year s Claim Previous Year s Claim Date of Service Type of Service Provider Signature & TAX ID # (Not payment Date) (Daycare/Baby Sitting/ Preschool/ Day Camp/Etc) (Have Provider Sign Here or Attach their Receipts) Amount of Claim Total of Dependent Care FSA Claim: $ Part VI. Healthcare Reimbursement Arrangement (HRA) Claim Information Please check the reimbursement option you prefer (Check, Direct Deposit,.
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