Fill - Free fillable Form F-ddc-0318 Dependent care claim form (FFGA)) PDF form

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DependentDayCareClaimForm

FirstFinancialAdministrators,Inc.

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CONTACTUSTODAY:

POBox161968,AltamonteSprings,FL32716|Online:www.ffga.com|Phone:866‐853‐FLEX

Faxnumber:800‐298‐7785|TechSupport:techsupport@ffga.com

FlexReceiptsandDocumentsonly:First_Financial_Receipts@Alegeus.com

EMPLOYEEINFORMATION(PleasePrint)

EMPLOYER FIRSTNAME MI LASTNAME

ADDRESS CITY STATE ZIP

PHONE(BetweenHoursof8am‐5pm) SSN EMAILADDRESS

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DEPENDENTDAYCAREEXPENSES

Dependent day care expenses must be for a dependent who is incapable of self-care or under the age of 13 at the time the care was

provided.

DATESCARE

PROVIDED



NAMEOFDEPENDENT AGE FROM TO NAME,ADDRESS,ANDSSN/TAXPAYER

ID#OFCAREPROVIDER

COSTFOR

CAREPERIOD

FFGUSE

ONLY

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



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

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TOTALDEPENDENTCAREAMOUNT

REQUESTED

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 

  

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PROVIDERSIGNATURE(Requiredifanitemizedreceiptisnotattached.)

Iprovidedthedependentcareasstatedabove.

CAREPROVIDERSORIGINALSIGNATURE:DATE:

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EMPLOYEESIGNATURE(REQUIRED)

IcertifythatIhaveincurredtheDependentDayCareexpenseformetoworkorlookforwork,andifmarried,myspousetoworkorlookfor

work.TheseexpensesareforaQualifyingPerson.Theseexpensesarenotforeducationalpurposestoattendkindergartenorhigher.I

acknowledge

thatIwillhavetoreportthecaregiver’sname,address,andTaxIdentificationNumberonForm2441.

IunderstandthatIcannotbereimburseduntiltheexpensehasbeenincurred;noprepayments.Icannotbereimburseduntilthefundshave

beenreceivedbymyemployeranddeposited inmyaccount.

Note:Ifyouhavedirectdeposit,FirstFinancialAdministrators,Inc.willnotpaybankchargesforinsufficientfunds.Pleasecontactyour

financialinstitutiontoverifydeposit.

EMPLOYEESIGNATURE:DATE:

F‐DDC‐0318 Seepage2forclaimfilingguidelines.

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FirstFinancialAdministrators, Inc.

POBox161968∙AltamonteSprings,FL32716

Phone:866‐853‐3539∙Fax:800‐298‐7785

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SUBMISSIONGUIDELINES

Pleasefollowtheseguidelinestoensurethatyourclaimsarereimbursedquickly.

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AcceptableDocumentation:

 Itemizedstatementwhichincludes:

 ProviderName

 QualifyingPerson’sName

 DateofService

 AmountChargedfortheCareServices

 TaxIdentificationNumber/SocialSecurityNumberofProvider

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UnacceptableDocumentation:

 Canceledchecks

 Debitcardorcreditcardreceipts

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Claimsforfutureservicesarenoteligibleforreimbursement.

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MailClaimFormsto:

FirstFinancialGroupofAmerica

FSADepartment

POBox161968

AltamonteSprings,FL32716

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FaxClaimFormsto:

800‐298‐7785

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EmailClaimFormsto:

First_Financial_Receipts@Alegeus.com

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Filloutaclaimformonline:

www.ffga.com

Completeyourclaimformonlineanduploaddocumentationonoursecureparticipantportalbylogginginto

www.ffga.com.

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FFFlexMobileApp:

FileaclaimformonyourmobiledeviceusingtheFFFlexMobileApp.AvailablefordownloadontheAppStoreor

GooglePlayStoreforAppleandAndroid

devices.

Visitwww.ffga.comformoreinformationaboutFlexibleSpendingAccounts.

F‐DDC‐0318

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