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Get TX FLEXTRA Dependent Care Reimbursement Claim Form

Mail to City of Austin FLEXTRA Dependent Care Reimbursement Claim Form Fax to Telephone CompuSys/Erisa Group Inc. 13706 Research Blvd Ste 308 Austin TX 78750 512 250-2937 800 933-7472 INSTRUCTIONS 1. Complete sign and date this form* Mail or Fax this form and documentation to Compusys/Erisa Group Austin* 2. Attach itemized documentation from the dependent care provider indicating the provider s name address tax identification number dates of service from-to name of the dependent services rendered and the amount paid* 3. If you do not have an itemized receipt have the dependent care provider complete sign and date Section C of this form* SECTION A EMPLOYEE INFORMATION Please Print EMPLOYEE NAME LAST FIRST MIDDLE SOCIAL SECURITY NUMBER DATE OF BIRTH MAILING ADDRESS IS THIS A NEW ADDRESS YES NO CITY STATE WORK PHONE HOME PHONE SECTION B DEPENDENT CARE INFORMATION DEPENDENT NAME RELATIONSHIP DEPENDENT CARE PROVIDER DATES OF SERVICE FROM TO ZIP CODE AMOUNT PAID SECTION C SERVICE PROVIDER CERTIFICATION To be completed by service provider as a receipt for services TAX I. D. /SOCIAL SECURITY NUMBER PROVIDER SIGNATURE DATE I want this reimbursement from my FLEXTRA Dependent Care Account. Specify Plan Year I certify that the charges attached or listed above are eligible dependent care expenses under the Internal Revenue Code the charges have been incurred and that I have not been reimbursed by nor are these charges reimbursable by any other source. I also certify that I will not claim these charges as a credit on my personal income tax return* I understand that failure to submit claims with all required documentation by MAY 31st following the close of the Plan Year March 15th will result in my expenses not being reimbursed and I will lose any money left in my account. Claims must be postmarked by MAY 31st. SIGNATURE If funds are available in your account checks are mailed by 5 p*m* Friday for claims received by Wednesday. Complete sign and date this form* Mail or Fax this form and documentation to Compusys/Erisa Group Austin* 2. Attach itemized documentation from the dependent care provider indicating the provider s name address tax identification number dates of service from-to name of the dependent services rendered and the amount paid* 3. Attach itemized documentation from the dependent care provider indicating the provider s name address tax identification number dates of service from-to name of the dependent services rendered and the amount paid* 3. If you do not have an itemized receipt have the dependent care provider complete sign and date Section C of this form* SECTION A EMPLOYEE INFORMATION Please Print EMPLOYEE NAME LAST FIRST MIDDLE SOCIAL SECURITY NUMBER DATE OF BIRTH MAILING ADDRESS IS THIS A NEW ADDRESS YES NO CITY STATE WORK PHONE HOME PHONE SECTION B DEPENDENT CARE INFORMATION DEPENDENT NAME RELATIONSHIP DEPENDENT CARE PROVIDER DATES OF SERVICE FROM TO ZIP CODE AMOUNT PAID SECTION C SERVICE PROVIDER CERTIFICATION To be completed by service provider as a receipt for services TAX I. .

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