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June 3, 1996

INC. FSA - CLAIM VOUCHER
Washington
Braintree, MA 02184
(781) 848-8477 (Fax)

EMPLOYER: _______________________________________________________

EMPLOYEE: ____________________________________________________ SS#: XXX -XX - _______
ADDRESS: ___________________________________________CITY:_____________________________________
STATE: __________ ZIP: _____________
PHONE: ( )__________________________
E-MAIL ADDRESS:
UNREIMBURSED MEDICAL EXPENSES (Participants & Eligible Dependents -as defined by the IRS guidelines)
ITEMS (group similar items)
DATE OF SERVICE
TOTAL: $__________________
DEPENDENT/CHILD CARE EXPENSES (daycare)

_____________________________________

OTHER ACCOUNT EXPENSES (e.g. COBRA)
_____________________________________

TRANSPORTATION ACCOUNT EXPENSES (For Participants Enrolled in Qualified Parking/Transit Plan ONLY)
PARKING (IRS Monthly max $230)

All medical claims submitted require copies of bills/statements/receipts showing date and type of service. (No cancelled checks/credit
card receipts). All claims must be received 2 days prior to claim payment day. Direct deposit payments are processed weekly
(Wednesday). Checks are processed at least twice a month (every other Wednesday). Please allow 3 business days to receive your
check. Minimum payment is $20.00.

This is to certify that I have incurred the expenses listed above that qualify for reimbursement under my employer’s Cafeteria Plan. I
have not been reimbursed from any other source including insurance programs or other programs offered by my employer. None of
these expenses have previously been submitted. I understand and agree that since these expenses are to be reimbursed they may not be
claimed as deductions for income tax purposes. Additionally, I am aware that unused funds may be forfeited or otherwise handled in
accordance with the plan document and the current IRS law. I hereby request reimbursement for these claims.

PARTICIPANT’S SIGNATURE: ________________________________________________ DATE: _________________
CLAIM PROCESSING & PROCEDURES

• PAYMENTS: DIRECT DEPOSIT PAYMENTS ARE PROCESSED WEEKLY (WEDNESDAY). PLEASE
ALLOW TWO BUSINESS DAYS FOR FUNDS TO BE IN YOUR ACCOUNT. CHECKS ARE ISSUED AT LEAST TWICE A MONTH (EVERY OTHER WEDNESDAY). • CLAIMS MUST BE RECEIVED AT LEAST 2 DAYS PRIOR TO THE SCHEDULED PAYMENT DAY TO BE
• MEDICAL CLAIMS SUBMITTED REQUIRE COPIES OF BILLS/STATEMENTS/RECEIPTS SHOWING DATE AND TYPE OF SERVICE. (NO CANCELLED CHECKS/CREDIT CARD RECEIPTS). • YOU MAY FAX A CLAIM AND YOUR RECEIPTS TO CPA, INC. PLEASE LIMIT TO 10 PAGES. • ELIGIBLE EXPENSES REQUIRE THE DATE OF SERVICE FALL WITHIN YOUR PLAN YEAR, NOT WHEN • GROUP EXPENSES TOGETHER ON ONE LINE (See Example Below) DATE INCURRED
IRS Reimbursable Expenses (examples). Please call CPA, Inc. if any questions.
Mileage traveled to/from a medical facility: (16.5 cents per mile effective 1/1/2010) Insulin and Testing Supplies

*IMPORTANT NOTE: Due to new Health Care Reform, Over-The-Counter items are no

longer eligible expenses, effective 1/1/2011.
The following items require a physician prescription each plan year stating the expense is
necessary to treat a particular medical condition/disease. Wellness procedures and programs are NOT
covered.
Health Club memberships

Source: http://town.dennis.ma.us/Pages/DennisMA_HR/employees/flex.pdf