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Of the provider of these dependent care services. All information provided by me is true and correct and may be relied upon by the administrator. Employee Signature: *FSA201A* Date: Fax completed forms to: 763-278-4004 866-278-4004 Mail completed forms to: Acclaim Benefits P.O. Box 47338 Minneapolis, MN 55447-0338 Contact Acclaim Benefits: 763-278-4312 800-333-3724 www.acclaimbenefits.com Completed Reimbursement Request Example Benefit Code 0 Service Start Date 2 0 6 - 1 Service End.

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