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CBIZ Flex Flexible Benefits Plan Claim Form Version 2. 01. 08 Employer Email SSN Phone - Un-reimbursed Medical Expense Claims Date Expense Incurred Name of Service Provider Expense Description Person for Whom Expense Incurred Net Amount Attach appropriate receipt s and submit with this claim form. Total Medical Care Expense Claim Dependent Care Expense Claims Name of Dependents Period Covered From To Name and Taxpayer Identification Number of Service Provider Amount Incurred Total Dependent Care Expense Claim Provider s Signature Read Carefully The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while or are not reimbursable under any other health plan coverage and that they were incurred by the participant or a legal dependent of the participant. The expenses qualify as valid Medical Care Expenses under Code 213 d as defined in the Flexible Spending Account Summary Plan Description Document the plan. The undersigned certifies that their family member has received the services described above on the dates indicated and the expenses qualify as valid Dependent Care Expenses as defined in the FSA Summary Plan Description Document. The undersigned fully understands that he or she is fully 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 or reimbursement is claimed is a proper expense under the Plan the undersigned may be liable for payment of all related taxes including federal state and or local income tax on amounts paid from the Plan which relate to such expense. Employee Signature Date Election and Claim Forms can be mailed or faxed to CBIZ Payroll Attn Flex 310 First St* Ste 600 Roanoke VA 24011 Please keep a copy for your records Fax 800-584-4185 Phone 800-815-3023 option 4 Email cbizflex cbiz. The expenses qualify as valid Medical Care Expenses under Code 213 d as defined in the Flexible Spending Account Summary Plan Description Document the plan. The undersigned certifies that their family member has received the services described above on the dates indicated and the expenses qualify as valid Dependent Care Expenses as defined in the FSA Summary Plan Description Document. The undersigned certifies that their family member has received the services described above on the dates indicated and the expenses qualify as valid Dependent Care Expenses as defined in the FSA Summary Plan Description Document. The undersigned fully understands that he or she is fully 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 or reimbursement is claimed is a proper expense under the Plan the undersigned may be liable for payment of all related taxes including federal state and or local income tax on amounts paid from the Plan which relate to such expense.

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