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Get Conexis Dependent Online Reimbursment Form
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How to use or fill out the Conexis Dependent Online Reimbursement Form online
Filling out the Conexis Dependent Online Reimbursement Form is a straightforward process that allows you to request reimbursement for eligible dependent care expenses. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.
Follow the steps to complete the form online.
- Click ‘Get Form’ button to access the Conexis Dependent Online Reimbursement Form and open it in your preferred editor.
- Begin by filling out the Employee Information section, which includes your employer name, full name, account number or Social Security number, and contact information such as your street address, city, state, zip code, and daytime phone number.
- In the Claim Information section, provide details about the dependent care provider, including their tax identification number or Social Security number, full address, and the name and date of birth of the dependent. Ensure you list all dates of service alongside the corresponding amounts requested for reimbursement.
- Check the appropriate box in the Provider Certification section to confirm that the services have been provided. If the provider has signed this section, no further documentation is required; otherwise, attach an itemized statement from your provider.
- Proceed to the Employee Certification section, where you must review and certify all statements regarding eligibility and submission of expenses. Provide your signature and the date.
- Once the form is completed, you can either save your changes, download a copy, print it out, or share it as needed.
Complete your Conexis Dependent Online Reimbursement Form today for timely reimbursement of eligible expenses.
Funds set aside in the dependent care FSA are pretax dollars, which reduces an employee's taxable income. It's important to note that all funds in the account must be used during the plan year and cannot be rolled over to the next.
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