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| Form Title: | WageWorks Dependent Care Flexible Spending Account Claim Form |
| Last Revised: | 1/2009 |
| Purpose: | Allows reimbursements from the WageWorks Dependent Care Flexible Spending Account. Plan effective 1/1/09. |
| Who Should Use the Form: | Employees contributing to Dependent Care Flexible Spending |
| Instructions: | Employee completes the form and signs. Mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512, OR fax toll-free to: 1-877-353-9236 (no cover page is required) |
| View/Fill Out the Form: | Click here to view and/or use the form in .pdf format |
| Problems? Contact: | Konnie Carrillo, x8706 |
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