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| Form Title: | Flexible Spending Accounts Claim Form |
| Last Revised: | 1/2007 |
| Purpose: | Allows reimbursements from Flexible Spending Accounts |
| Who Should Use the Form: |
Employees contributing to Flexible Spending |
| Instructions: | Employee completes the form and signs. The Day Care Provider must also sign either the form or the invoice. Submit to PayFlex System USA, Inc., P. O. Box 3039, Omaha, NE 68103-3039 OR fax to 402-231-4310 (no cover page is required) |
View the Form: |
Click
Here to View the Form in PDF |
| Form Download Information | |
| File Format: | MS Excel (.xls) |
| Download File: | Click Here to Download the Form |
| Problems? Contact: | Konnie Carrillo, x8706 |
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