Reimbursement Request Form

Eide Bailly Employee Benefits
U.S. Bancorp Center
800 Nicollet Mall, Suite 1350
Minneapolis, MN 55402-7033
Phone: 612.253.6633 | 1.800.300.1672
Fax: 612.253.6622
www.eidebaillybenefits.com
Reimbursement Request Form
Please Complete All Information And Attach Itemized Documentation For Each Expense Listed
Benefit Year: _______________
Employer: __________________________________________________________________
Social Security Number: XXX - XX - ____________
First Name: _______________________ MI: _______ Last Name: ____________________________________
Address: _________________________________________________________________________
City: _______________________________________ State: ____ Zip: __________________________
Daytime Phone: (_____) ____________________________
E-mail: _______________________________________________
Unreimbursed Medical/Dental Expense (for you, your spouse and your dependents)
Date(s) of
Service
(MM/DD/YY)
Person for Whom
Expense Incurred
Expense Description
Name of Service Provider
Net Amount*
1
2
3
4
5
6
Note: If you need additional space, attach a
separate sheet of paper.
Total Unreimbursed Medical/Dental Expense Claimed
$0.00
*Net amount is the amount of the claim not reimbursed to you through another plan; i.e. health or dental insurance.
Unreimbursed Dependent Care Expense (Daycare Expenses)
Period Covered
from (MM/DD/YY) to (MM/DD/YY)
Name of
Dependent
7
Identify below the Provider Name, Tax ID and Signature
OR attach a receipt from the Provider with the Provider
Name, Tax ID and Signature. The information is required
with each submission.
Actual Amount
Incurred
Provider Signature -
8
Provider Signature -
9
Provider Signature -
Total Unreimbursed Dependent Care Expense Claim
$0.00
Note: If same Dependent Care Provider for each claim listed above, signature is required only once.
Read Carefully
The undersigned participant in the plan certifies that all expenses for which reimbursement of payment is claimed by submission of this form, were incurred
during a period while the undersigned was covered under the company’s cafeteria plan. The undersigned fully understands that he/she alone is responsible
for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned and that, unless an expense for which
payment of reimbursement is claimed is a proper expense under the plan, the undersigned may be liable for payment of all related federal, state, or city
income tax on amounts paid from the plan which relate to such expense.
**Don't forget to sign and date before sending in completed form**
Date
Employee Please Sign Here
Rev 06/2012
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