Fillable Employee Benefit Systems Third Party Administration Services (City of Council Bluffs)

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Employee Benefit Systems Third Party Administration Services (City of Council Bluffs)

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BROWSE CITY OF COUNCIL BLUFFS (IA) FORMS

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EBS F023 (2/2013)
FLEX Request for Reimbursement
Please complete all sections - please check the following box if this is a re-submission. Re-submission
Name: Social Security Number or EE ID number:
Home Address:
Employer:
City: State: Zip: Daytime phone:
Check here if this is a new address
Email Address:
Flexible Spending Account Reimbursement-Attach an itemized receipt, an Explanation of Benefits, or other verification (originals or
photocopies) of each expense claimed, indicating the service(s) provided, date(s) of service, and corresponding charges. Credit card receipts,
cancelled checks, balance forward statements are not eligible forms of documentation.
Person Receiving Care Relationship Date of
Service
Description of Expense Care Provider
(Name of Doctor, Clinic, Hospital)
Amount
Claimed
Dependent Care Reimbursement-Attach an itemized receipt or other verification of each expense claimed, indicating the service(s)
provided, date(s) of service, and corresponding charges. This documentation is not needed if care provider’s certification is obtained below.
Dependent Receiving
Care
Relationship Age Dates of Care Care Provider
(Name and SSN or T.I.N.)
Amount
Claimed
I certify that the dependent care expenses shown above are valid.
Signature of Dependent Care Provider: Date:
Employee Certification:
I request reimbursement from my Employee Reimbursement Account(s) for the expenses itemized above. I certify that the expenses for which reimbursement is
requested under the reimbursement account(s) were for services received either by me or my eligible dependent(s). I also certify that I or my eligible dependent(s) have received the services
described on the dates indicated, and these are my out-of-pocket expenses that qualify as valid expenses under the plan and the Internal Revenue Code. I certify that I have not been reimbursed for
the itemized expenses and that I will not seek reimbursement under any other plan covering health benefits. I also certify that these expenses are to alleviate a medical condition and not just merely
beneficial to my general health. I understand that if I, my spouse, or dependents make contributions to a Health Savings Account (HSA) or receive HSA contributions from anyone else, I must have a
Limited Purpose Medical Reimbursement Account which can only pay qualifying expenses related to vision and dental care. I further understand that reimbursed expenses cannot be claimed as
credits or deductions on my personal tax return. To the best of my knowledge and belief, my statements on this form are complete and true.
Employee Signature: (REQUIRED) Date:
Submit by email
flex@ebs-tpa.com
Submit by Fax
Fax: 888-511-3743
# of pages: ___________
Us
can
EBS
help:
Employee Benefit Systems Third Party Administration Services
Contact
Employee Benefit Systems 214 North Main Street PO Box 1053 Burlington, IA 52601
Phone: 800-373-1327 Fax: 888-511-3743 flex@ebs-tpa.com
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EBS F023 (2/2013)
GUIDELINES FOR ELIGIBLE REIMBURSMENT
General Guidelines
Employee Reimbursement Accounts are a part of Section 125 of the Internal Revenue Code that governs the tax status of Flexible
Benefit Plans. Eligibility for pre-tax reimbursement is covered in Code Sections 105 /106 (Accident/Health Plans) and Section
129 (Dependant Care).
• Reimbursement will be made directly to you; you are responsible for paying your provider.
• According to the Internal Revenue Code, if you apply for reimbursement of expenses that the IRS later determines to be
ineligible, those reimbursements may be taxed as ordinary income and certain penalties may apply.
• Ineligible expenses include overpayments of reimbursable expenses, expenses that have already been paid from some other
source, expenses for other than vision and dental services under a Limited Purpose Medical Reimbursement Account, and
expenses not eligible for reimbursement as described by the Plan or as provided by the IRS.
• If you have a General Purpose Medical Reimbursement Account, none of you, your spouse, or dependents are eligible to
make contributions to or receive contributions in an HSA.
• Cafeteria plans may only reimburse expenses incurred in the plan year. An expense is incurred when the service that gives
rise to the expense is provided, when the expense is paid is irrelevant.
• For specific detail on claim filing, reimbursement, and review procedures, please reference your Summary Plan Description.
Medical Expense Reimbursement
Eligible expenses are qualified medical, dental and vision expenses that are not eligible for reimbursement from any other
source.
• Expenses that can be reimbursed under your health insurance plan should not be included on this form.
• Expenses for services which are not medically necessary (i.e. cosmetic) should not be included on this form.
• You may be reimbursed for expenses for yourself, your spouse, and your dependents, as defined in the Internal Revenue
Code.
• Only qualifying expenses related to vision and dental care will be paid or reimbursed from a Limited Purpose Medical
Reimbursement Account.
• Eligible expenses and services are detailed on the EBS website at www.ebs-tpa.com
Dependent Care Reimbursement
• Expenses to provide care for your eligible dependents may qualify for reimbursement. Eligible dependents include your
qualifying child under age 13, your disabled spouse or disabled qualifying child who lives with you for more than half the
year, and a disabled qualifying relative who lives with you for more than half the year, for whom you provide over half his or
her support.
• To be eligible, you must be working while your dependents receive care. If you are married, your spouse must be a wage
earner or a full-time student for at least 5 months during the year, or is disabled and unable to provide for his or her own
care.
• Expenses eligible for reimbursement are those incurred to enable you to be gainfully employed. Covered expenses include
licensed day care centers or individuals other than your dependents who provide care for your children in or outside your
home.
• You will be required to provide the name, address, and social security (or other tax I.D.) number of your day care provider
on your federal income tax forms at year end.
• If claims submitted are greater than the balance in your dependent care account, reimbursement will be limited to your
account balance. The un-reimbursed amount will carry forward to subsequent months in the plan year; you need not
resubmit.
• IRS regulations limit the amount of reimbursement expense for dependent care to the lower of the annual earned income of
you or your spouse. If your spouse is disabled or a full-time student, this limitation assumes that your spouse earns $200 per
month for one dependent or $400 per month for two or more dependents.
• An additional IRS Regulation limits the amount you can contribute to the dependent care account to $5000 for a single
parent with children, $5000 for a married parent filing jointly, and $2,500 for a married parent filing separately.
• Under IRS Regulations, qualified individuals can receive a tax credit for dependent care costs. This credit can be claimed on
your personal tax return. You cannot claim the tax credit for any dependent care costs reimbursed from the Dependent Care
Reimbursement Account. The maximum amount that can be used for the tax credit is reduced by the amount you use from
the Dependent Care Reimbursement Account.
Us
can
EBS
help:
Employee Benefit Systems Third Party Administration Services
Contact
Employee Benefit Systems 214 North Main Street PO Box 1053 Burlington, IA 52601
Phone: 800-373-1327 Fax: 888-511-3743 flex@ebs-tpa.com
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Employee Benefit Systems Third Party Administration Services (City of Council Bluffs)

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Completed 5 August 2020

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