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Employee Information To avoid claim delay, all sections must be completed  \n\n| Social Security Number | Last Name |  | First Name | Middle Initial |  |\n| --- | --- | --- | --- | --- | --- |\n| Street Address |  | City |  | State | Zip Code |\n| Email Address* |  |  |  |  | *See email consent on back of form. |\n\nB. Employer Information  \nEmployer Name:  \nC. Dependent Care Expense Information  \n\n| Qualifying Person’s Name | Relationship to Employee\u003Cbr>􀂆 Spouse 􀂆 Child 􀂆 Other | Date of Birth (MM/DD/YYYY) |\n| --- | --- | --- |\n| Date(s) of Service (MM-DD-YYYY)\u003Cbr>From - - Thru - - Amount Paid $   |  |  |\n| Qualifying Person’s Name | Relationship to Employee\u003Cbr>􀂆 Spouse 􀂆 Child 􀂆 Other | Date of Birth (MM/DD/YYYY) |\n| Date(s) of Service (MM-DD-YYYY)\u003Cbr>From - - Thru - - Amount Paid $   |  |  |\n| If you would like your Dependent Care claim set up as a recurring claim for the year, please check this box. ☐\u003Cbr>For recurring Dependent Care claims, please include an itemized receipt that includes the total cost of your daycare expenses for the plan year. Your claim will be entered based on your annual election and paid in full as payroll deposits accumulate in your account. It will be your responsibility to advise Medcom if you have a cost change. |  |  |\n\nD. Provider Information  \n\n| Caregiver Name\u003Cbr>Relative: 􀂆 Yes 􀂆 No | Social Security Number or Tax ID of Caregiver |\n| --- | --- |\n| Address of Caregiver/Provider | Telephone Number of Caregiver/Provider |\n\nE. Employee/Caregiver Certification  \n\n| EMPLOYEE- I certify that all the expenses listed above for which I am seeking reimbursement from the Dependent Care Account have been incurred. I further certify that these expenses have not been reimbursed, nor shall I seek reimbursement, from any other dependent care assistance program. I also certify that I have not, and will not, claim a tax deduction or credit for these expenses on my federal income tax return, nor will I claim a tax deduction or credit for these expenses on my state or local tax returns in violation of state or local law. I further certify that the above dependent care expenses are for the care of a Qualifying Person and do not include separate charges for food, clothing, education, entertainment, activities, late fees, or overnight care. I agree to submit and retain sufficient documentation for any expense for which I seek reimbursement. Any person who knowingly and with intent to defraud that files a statement of claim containing any materially incomplete, misleading, or false information is guilty of a crime.\u003Cbr>Signature of Employee:  Date: |\n| --- |\n| CAREGIVER- I certify that I am a qualified caregiver as defined by the Internal Revenue Code and that the expenses for services claimed above have actually been provided. Any person who knowingly and with intent that files a statement of claim containing any materially false, incomplete or misleading information is guilty of a crime.\u003Cbr>Signature of Caregiver:  Date: |\n\nDependent Care Reimbursement Provider Statement  \nInstructions for submitting your claim  \nPlease make copies for your records as claim information cannot be returned.  \nPlease do not highlight anything on the form as this makes it illegible.  \nSection A-Employee Information  \nComplete all information in this section. Any changes should also be reported to your employer.  \nEmail Consent-By providing your email address you are consenting to receive electronic communications at this email address, for any and all matters permitted by law regarding this Plan which is sent by, or on behalf of, the Plan or your employer. By providing your email address, you will no longer receive printed copies of communication which are sent to you electronically. I certify that I have access to this email address and am able to receive electronic messages with attachments at this email address. I understand that I may request a paper copy of any correspondence provided electronically at no charge by contacting the Pla","cbCaicqi3BRnolA4","https://ap.wps.com/l/cbCaicqi3BRnolA4","pdf",341349,"English","# Employee Information\n## Employer Information\n## Dependent Care Expense Information\n## Provider Information\n## Employee/Caregiver Certification\n# Instructions for Submitting Your Claim\n## Email Consent\n## Qualifying Person Definition","[{\"question\":\"哪些信息需要在A、B、C、D部分完整填写？\",\"answer\":\"A部分填写员工信息，B部分填写雇主信息，C部分按合格照护人列出照护费用与服务日期及金额，D部分填写照护者/提供者信息（含社保号或税号、地址与电话）。\"},{\"question\":\"费用如何按受抚养人进行归类？\",\"answer\":\"需要按每位合格照护人的姓名分别列出并分开填写服务日期与支付金额。\"},{\"question\":\"合格照护人包括哪些类型？\",\"answer\":\"合格照护人通常包括：13岁以下的符合条件的受抚养子女、因身体或精神无法自理且与员工同住超过半年的配偶，以及同住超过半年的其他符合条件人员。文中还要求进一步参照相关税务出版物说明。\"}]","FSA Daycare Provider Receipt Form | PDF",1789786766]