Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering your name, including your last name, first name, and middle initial, in the designated fields at the top of the form.
3. Provide your social security number in the specified field to ensure proper identification.
4. Fill in your mailing address, including city, state, and zip code, to ensure correspondence is directed accurately.
5. For the dependent care spending account section, identify the names and ages of your dependents. For each dependent, provide the name and age.
6. If available, have your care provider certify the dependent care services by signing the certification section on the form.
7. For the medical spending account section, enter the date of service, the healthcare provider's name, type of medical expense, and the patient's name and relationship to you.
8. Finally, review all information for accuracy. Once complete, you can save the form, download it, print, or share it as needed.

Complete your claims online to simplify your documentation process and enhance your experience.