Reimbursement Request Form - 121 Benefits

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121 Benefits
730 2nd Ave. S., Ste. 400
730 Building
Minneapolis, MN 55402-2446
Phone: 800.300.1672
Fax: 877.918.3622
www.121benefits.com
Reimbursement Request Form
Please Complete All Information And Attach Itemized Documentation For Each Expense Listed
Benefit Year: _______________
Employer: __________________________________________________________________
Social Security Number: XXX - XX - ____________
First Name: _______________________ MI: _______ Last Name: ____________________________________
Address: _________________________________________________________________________
City: _______________________________________ State: ____ Zip: __________________________
Daytime Phone: (_____) ____________________________
E-mail: _______________________________________________
Unreimbursed Medical/Dental Expense (for you, your spouse and your dependents)
Date(s) of
Person for Whom
Net Amount*
Service
Expense Description
Name of Service Provider
Expense Incurred
(MM/DD/YY)
1
2
3
4
5
6
Note: If you need additional space, attach a
Total Unreimbursed Medical/Dental Expense Claimed
separate sheet of paper.
*Net amount is the amount of the claim not reimbursed to you through another plan; i.e. health or dental insurance.
Unreimbursed Dependent Care Expense (Daycare Expenses)
Identify below the Provider Name, Tax ID and Signature
Period Covered
Name of
Actual Amount
OR attach a receipt from the Provider with the Provider
Name, Tax ID and Signature. The information is required
from (MM/DD/YY) to (MM/DD/YY)
Dependent
Incurred
with each submission.
7
Provider Signature -
8
Provider Signature -
9
Provider Signature -
Total Unreimbursed Dependent Care Expense Claim
Note: If same Dependent Care Provider for each claim listed above, signature is required only once.
Read Carefully
The undersigned participant in the plan certifies that all expenses for which reimbursement of payment is claimed by submission of this form, were
incurred during a period while the undersigned was covered under the company’s cafeteria plan. The undersigned fully understands that he/she alone is
responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned and that, unless an
expense for which payment of reimbursement is claimed is a proper expense under the plan, the undersigned may be liable for payment of all related
federal, state, or city income tax on amounts paid from the plan which relate to such expense.
Date
Employee Please Sign Here
Rev 11/2016
121 Benefits
730 2nd Ave. S., Ste. 400
730 Building
Minneapolis, MN 55402-2446
Phone: 800.300.1672
Fax: 877.918.3622
www.121benefits.com
Reimbursement Request Form
Please Complete All Information And Attach Itemized Documentation For Each Expense Listed
Benefit Year: _______________
Employer: __________________________________________________________________
Social Security Number: XXX - XX - ____________
First Name: _______________________ MI: _______ Last Name: ____________________________________
Address: _________________________________________________________________________
City: _______________________________________ State: ____ Zip: __________________________
Daytime Phone: (_____) ____________________________
E-mail: _______________________________________________
Unreimbursed Medical/Dental Expense (for you, your spouse and your dependents)
Date(s) of
Person for Whom
Net Amount*
Service
Expense Description
Name of Service Provider
Expense Incurred
(MM/DD/YY)
1
2
3
4
5
6
Note: If you need additional space, attach a
Total Unreimbursed Medical/Dental Expense Claimed
separate sheet of paper.
*Net amount is the amount of the claim not reimbursed to you through another plan; i.e. health or dental insurance.
Unreimbursed Dependent Care Expense (Daycare Expenses)
Identify below the Provider Name, Tax ID and Signature
Period Covered
Name of
Actual Amount
OR attach a receipt from the Provider with the Provider
Name, Tax ID and Signature. The information is required
from (MM/DD/YY) to (MM/DD/YY)
Dependent
Incurred
with each submission.
7
Provider Signature -
8
Provider Signature -
9
Provider Signature -
Total Unreimbursed Dependent Care Expense Claim
Note: If same Dependent Care Provider for each claim listed above, signature is required only once.
Read Carefully
The undersigned participant in the plan certifies that all expenses for which reimbursement of payment is claimed by submission of this form, were
incurred during a period while the undersigned was covered under the company’s cafeteria plan. The undersigned fully understands that he/she alone is
responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned and that, unless an
expense for which payment of reimbursement is claimed is a proper expense under the plan, the undersigned may be liable for payment of all related
federal, state, or city income tax on amounts paid from the plan which relate to such expense.
Date
Employee Please Sign Here
Rev 11/2016

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