Dependent Care Flexible Spending Account (FSA) Claim Form
Employer Name:
Employee Name:
Last First Mi
SS#:
Employee Address:
Street City State ZIP
PHONE:
Email Address:
Please check if this is a new address
* Proof of expense must be provided along with the information below.
Dependent Care FSA (Child Care) Description of Expenses
Date of Service
From To
Age
Dependent Care
Provider Name
Tax ID# or
SSN of Child
Care Provider
Description of Service
Claim Amount
$
$
$
$
$
$
$
$
EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT
I certify that the expenses for reimbursement indicated on this substantiation form were incurred by me (and/or my spouse and/or
eligible dependents), and were not reimbursed by any other plan nor will I seek reimbursement from any other source. To the best of my
knowledge and belief, the expenses are eligible for reimbursement under my Reimbursement Plans. I (or we) will not use the expense
reimbursed through this account as deductions or credits when filing my (our) individual income tax return.
Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.
Employee Signature: _________________________________________________ Date: ________ /________ /________
FOR PROCESSING, SEND TO:
EMAIL: benefits@qnins.com
PHONE: (318) 429-0529
Querbes & Nelson
P.O. Box 1802
Shreveport, LA 71161-1802
Total:
Centenary College of Louisiana
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signature
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