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REQUEST FOR REIMBURSEMENT FORM
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SERVICE INFORMATION
Service Type *
Service Date *
(mm/dd/yyyy)
Service Description *
Service Provider *
Amount Paid *

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UPLOAD RECEIPTS
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SUBMIT REQUEST
JOHN DOE
TASC ID: 9999-9999-9999

DISCLAIMER
I Agree *
To the best of my knowledge and belief, my statements on this Request for Reimbursement are complete and true. I am requesting reimbursement only for eligible expenses incurred during the applicable Plan Year for eligible participants and/or eligible dependents as defined under the plan and applicable law. I certify these expenses have not been previously reimbursed under this or any other benefit plan and will not be claimed as an income tax deduction or credit. I further understand it is my responsibility to comply with plan and regulatory guidelines and to avoid submitting duplicate or ineligible requests. I authorize my FlexSystem or DirectPay account to be reduced by the amount requested.
SUBMITTED REQUESTS
Requests submitted previously in this session.
Service DateService DescriptionService Amount
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