DependentDayCareClaimForm
FirstFinancialAdministrators,Inc.
CONTACTUSTODAY:
POBox161968,AltamonteSprings,FL32716|Online:www.ffga.com|Phone:866853FLEX
Faxnumber:8002987785|TechSupport:techsupport@ffga.com
FlexReceiptsandDocumentsonly:First_Financial_Receipts@Alegeus.com
EMPLOYEEINFORMATION(PleasePrint)
EMPLOYER FIRSTNAME MI LASTNAME
ADDRESS CITY STATE ZIP
PHONE(BetweenHoursof8am5pm) SSN EMAILADDRESS
DEPENDENTDAYCAREEXPENSES
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.
DATESCARE
PROVIDED
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NAMEOFDEPENDENT AGE FROM TO NAME,ADDRESS,ANDSSN/TAXPAYER
ID#OFCAREPROVIDER
COSTFOR
CAREPERIOD
FFGUSE
ONLY
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
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TOTALDEPENDENTCAREAMOUNT
REQUESTED
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PROVIDERSIGNATURE(Requiredifanitemizedreceiptisnotattached.)
Iprovidedthedependentcareasstatedabove.
CAREPROVIDERSORIGINALSIGNATURE:DATE:
EMPLOYEESIGNATURE(REQUIRED)
IcertifythatIhaveincurredtheDependentDayCareexpenseformetoworkorlookforwork,andifmarried,myspousetoworkorlookfor
work.TheseexpensesareforaQualifyingPerson.Theseexpensesarenotforeducationalpurposestoattendkindergartenorhigher.I
acknowledge
thatIwillhavetoreportthecaregiver’sname,address,andTaxIdentificationNumberonForm2441.
IunderstandthatIcannotbereimburseduntiltheexpensehasbeenincurred;noprepayments.Icannotbereimburseduntilthefundshave
beenreceivedbymyemployeranddeposited inmyaccount.
Note:Ifyouhavedirectdeposit,FirstFinancialAdministrators,Inc.willnotpaybankchargesforinsufficientfunds.Pleasecontactyour
financialinstitutiontoverifydeposit.
EMPLOYEESIGNATURE:DATE:
FDDC0318 Seepage2forclaimfilingguidelines.
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FirstFinancialAdministrators, Inc.
POBox161968∙AltamonteSprings,FL32716
Phone:8668533539∙Fax:8002987785
SUBMISSIONGUIDELINES
Pleasefollowtheseguidelinestoensurethatyourclaimsarereimbursedquickly.
AcceptableDocumentation:
Itemizedstatementwhichincludes:
ProviderName
QualifyingPerson’sName
DateofService
AmountChargedfortheCareServices
TaxIdentificationNumber/SocialSecurityNumberofProvider
UnacceptableDocumentation:
Canceledchecks
Debitcardorcreditcardreceipts
Claimsforfutureservicesarenoteligibleforreimbursement.
MailClaimFormsto:
FirstFinancialGroupofAmerica
FSADepartment
POBox161968
AltamonteSprings,FL32716
FaxClaimFormsto:
8002987785
EmailClaimFormsto:
First_Financial_Receipts@Alegeus.com
Filloutaclaimformonline:
www.ffga.com
Completeyourclaimformonlineanduploaddocumentationonoursecureparticipantportalbylogginginto
www.ffga.com.
FFFlexMobileApp:
FileaclaimformonyourmobiledeviceusingtheFFFlexMobileApp.AvailablefordownloadontheAppStoreor
GooglePlayStoreforAppleandAndroid
devices.
Visitwww.ffga.comformoreinformationaboutFlexibleSpendingAccounts.
FDDC0318
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