FSA Dependent Care Reimbursement Claim Form - Jan 2015

This form is used to request reimbursement for dependent care expenses through a flexible spending account. This form should be submitted to the employee's employer or the flexible spending account administrator. Employees who have a flexible spending account for dependent care expenses should fill out this form.

Employees who have a flexible spending account for dependent care expenses.

The completed FSA Dependent Care Reimbursement Claim Form should be submitted to the employee's employer or the flexible spending account administrator.