Get Money Claim Form

Filling out the Money Claim Form online can be a straightforward process when you understand each section and requirement. This guide provides detailed instructions to ensure you can complete the form correctly and efficiently.

Follow the steps to successfully complete the Money Claim Form

1. Click the ‘Get Form’ button to obtain the Money Claim Form and open it for editing.
2. Begin by completing the personal data section at the top of the form. This includes your name, home phone number, street address, city, state, zip code, social security number or employee/member ID number, employer name, and daytime phone number. If you have moved recently, check the box indicating a new address.
3. Review the certification statements provided in the form, confirming your understanding and agreement to use your Flexible Spending Account (FSA) only for eligible expenses. Ensure you sign and date the form in the designated area.
4. In the payment type section, place a check mark in the appropriate boxes that apply to your claim and enter the respective dollar amounts for each type of expense. Ensure to attach any necessary documentation for transactions.
5. For medical FSA claims, complete the section by entering the service date, name of the individual receiving the service, their relationship to you, the providing service provider, and the amount you are responsible for. Make sure everything is filled out neatly.
6. Complete the dependent care FSA section with the required details such as the name of the person receiving care, their relationship to you, their age, and the service provider’s name and address. Be sure to include the service dates.
7. Double-check all entries for accuracy and completeness. Retain copies of the completed form and all associated documents for your records.
8. Once all sections are filled out and reviewed, you can save your changes, then choose to download, print, or share the completed form as needed.

Ready to file your claims? Complete your Money Claim Form online today!