IRS AND OTHER REQUIRED TERMS & CONDITIONS ACCEPTABLE FSA PLAN TERMS:

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1 Ph: or Flexible Spending Accounts Enrollment and Change Application Open Enrollment New Hire Change Change Reasons: Rehired Employee Marriage Legal Separation Divorce Death Birth Adoption Dependent Change Involuntary Loss of Other Coverage COBRA State Continuation (COC) Return or Go on Leave of Absence Other Change Reason for Application: Date of Event: Employer Name: Southwestern OR Community College Group #9111 Member ID: Phone #: - - Your Social Security Number or your unique ID Number assigned by your program sponsor. Name: Address: Last Street First Apt. M.I. Address: City State Zip Benefit Election Pay Periods / year: Other: Healthcare Election (Maximum annual election is $5,000) Per Pay Period Amount X Number of Pay Periods = Your Annual Election (Enter this amount here.) Dependent Care Election (DAYCARE) IRS maximum set at $5,000, or $2,500 if married and filing separate income tax returns. Effective Date: Per Pay Period Amount X Number of Pay Periods = Your Annual Election (Enter this amount here.) / / $,. $,. Benefits Card When you enroll in the Healthcare FSA, you will automatically receive a benefits card. If you would like to order an additional card for your dependent, please complete below. Yes, please order a Benefits MasterCard for my dependent. Please provide name and ID#. A Benefits MasterCard pays directly from your FSA at the point of service. (See page 2 for more details.) Name: Dependent Last Name Dependent First Name Dependent Social Security Number or unique ID Number Direct Deposit Direct Deposit will electronically deposit your reimbursement to your bank account. Yes, enroll me in Direct Deposit. Checking Savings Name of Bank: Transit Routing # (First 9 digits on the bottom of your check) Account # Protected Health Information Authorization Yes, I authorize BenefitHelp Solutions to share my Protected Health Information (PHI) information with: Name: Relationship: Last First For: All benefits / accounts Specific Account(s): For the purpose of: Any and all information Only eligibility and balance info Only claim status info Participant Authorization I have read and agree to the terms and conditions on pages 1 and 2 and authorize my employer to reduce my salary on a per pay period basis. I understand that my election cannot be changed or revoked unless I experience a qualified status change event. Participant Refusal I waive participation in the Flexible Spending Accounts. I understand that if I elect not to participate, I cannot enter the program until next open enrollment unless I experience a status change in accordance with Internal Revenue Code Section 125 and submit the changes within 30 days of the qualified status change event. Employee Signature Date Please submit this completed form to your HR department. Page 1 of EnrollBC (10/09)

2 BENEFITS MASTERCARD The Benefits MasterCard provides direct access to your Flexible Spending Account (FSA), allowing you to pay for eligible health care expenses at qualified locations wherever MasterCard TM is accepted. When you use your Benefits MasterCard, you no longer have to pay for eligible expenses out of your pocket and wait for reimbursement, since money is deducted directly from your FSA account at the time of purchase. You may have to submit supporting documentation for certain purchases. When using your Benefits MasterCard at grocery stores and pharmacies, simply swipe your card first and choose Credit if asked. The card is a smart card in that it will only pay for IRS eligible FSA purchases. The store clerk will ask you for another form of payment to pay for your other purchases. You then pay for the non-fsa-eligible items with another card, cash, or check. Your IRS eligible purchases are automatically approved and paid directly from your FSA account. That s it - no claim forms to submit! When paying for services provided by a medical, dental, or vision provider, the Benefits MasterCard can automatically approve services that match a set copay or a multiple of that copay (not a percentage coinsurance) from your group health plan(s). Supporting documentation for these services is not needed; however, if the provider s charge is other than a copay you can still use the Benefits MasterCard and benefit from having the expense directly deducted from your account, you will just need to submit supporting documentation. DIRECT DEPOSIT By having your Flexible Spending Account reimbursement directly deposited into your bank account, you eliminate the hassle of having to go to the bank each time you receive a check. Instead of receiving a reimbursement check in the mail, you will receive a Direct Deposit Remittance Advice. The Remittance Advice will indicate the date your claim was paid, the amount that will be deposited to your bank account and an Explanation of Benefits (EOB). All direct deposits will be initiated on the same day as the normal check reimbursement date. Deposits may take up to two (2) business days to appear in the designated account. Should you make any changes to your bank account, such as account closure or change in account number, please notify BenefitHelp Solutions immediately. If there is an interruption in the direct deposit service, you will receive checks for any reimbursement claims paid during that time. You may cancel participation in the direct deposit program at any time. PHI - Authorization to Release Reimbursement Account Information to Family Members or Designated Individuals By completing the Protected Health Information Authorization section and signing this application, I hereby authorize the use and disclosure of my individually identifiable health information as described. I understand that this authorization is voluntary and that I may revoke it at any time by submitting my revocation in writing to BenefitHelp Solutions. Any uses or disclosures already made with my permission cannot be taken back. I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure and no longer protected under federal law. Information obtained or disclosed with this authorization will be limited to the minimum information needed to achieve the purpose. IRS AND OTHER REQUIRED TERMS & CONDITIONS 1. ACCEPTABLE FSA PLAN TERMS: I agree to abide by the terms, conditions and provisions of the Plan contained in the Company s Plan Document. I acknowledge my right to examine the Plan Document or obtain a copy from my Human Resources department. 2. RESPONSIBILITY: I acknowledge that the Internal Revenue Code permits me to claim reimbursement only for my tax deductible expenses incurred after the effective date of my FSA elections and I assume full responsibility for all taxes, penalties, interest or other consequences which may be assessed to me by any state, federal or other governmental taxing authority as a result of my requesting and receiving reimbursement from the FSA for disallowed expenses. I will only use my account to pay for eligible Internal Revenue Code (IRC) 213d health care expenses for myself and/or my tax dependents. Expenses cannot be reimbursed by any other plan. If requested, I will provide appropriate supporting documentation within the specified time frame. I understand that I cannot change or revoke my election until the open enrollment period for the new Plan Year. I will be able to change my election if I have a change in status as outlined in the Plan Document. 3. DEPENDENT CARE: I understand that the Internal Revenue Code prohibits me from claiming the Federal Child Care Tax Credit for dependent care assistance expenses which are reimbursed to me by the FSA. 4. PLAN MODIFICATION: I have been informed that the FSA offered by my employer may be modified from time to time and I agree that my employer may cancel or amend the FSA according to their independent judgement and discretion without my consent or prior notice to me. 5. SOCIAL SECURITY: I choose to participate in the FSA knowing that my salary reduction elections may reduce my FICA withholdings (Social Security) and that this may reduce my Social Security benefits upon retirement. 6. FORFEITURE: I understand that I must claim reimbursement for eligible expenses incurred during the plan year for which I was an active participant within the runout period of the plan year (and the Grace Period if applicable) as stated in my Summary Plan Description. If any unused amounts remain in my account(s) these amounts will be forfeited. 7. BENEFITS MASTERCARD: If it is determined that the Benefits MasterCard paid for an ineligible expense, I will either refund my account the amount of the ineligible expense or offset the ineligible expense with an eligible expense. I understand that if I do not provide supporting documentation as required, my Benefits MasterCard may be deactivated until my account is settled. By declining to order a Benefits MasterCard at Open Enrollment or when first offered, I may not be able to order one until the next Open Enrollment period. 8. HSA CONTRIBUTIONS: I understand that if my children, spouse, or I participate in an HSA Plan, HSA contributions may be disallowed if any HSA Participants also participate in the Healthcare FSA Election Account. 9. STATUS CHANGE: Unless otherwise noted in your Plan Documents, Qualified Status Changes (QSC) must be submitted within 30 days of the event. Please discuss with your Human Resources department to determine if your event is a QSC. If there s an election change, I understand that additional funds due to an increase in my election can only be used for claims incurred on or after the date of change. Page 2 of 2 Rev. 9/2009

3 BENEFITS MASTERCARD Questions & Answers 1. What is a Benefits MasterCard? The Benefits MasterCard provides direct access to Flexible Spending Account funds, allowing you to pay for eligible health care expenses at qualified locations wherever MasterCard TM is accepted. The amount of the transaction will be automatically deducted from your account to pay the merchant or provider of service. 2. What is the advantage of the Benefits MasterCard? The primary advantage of using the Benefits MasterCard is that you do not have to pay for eligible IRS expenses out of your own pocket, submit a claim form and wait to be reimbursed for the expense. The money is deducted directly from your flexible spending account at the time of purchase. 3. When can I request a Benefits MasterCard? You can request a Benefits MasterCard any time. If you have a card, you may request a second card for a family member at any time. 4. What is IIAS? IIAS or Inventory Information Approval System (IIAS) is designed to allow healthcare items to be purchased with your Benefits MasterCard at non-healthcare locations such as wholesale clubs, discount stores and pharmacies. Go to for more information. 5. How will your Benefits MasterCard work at an IIAS retailer? You may purchase healthcare items from certain retailers when you use your card. You may be asked by the retailer at the time of purchase to provide another form of payment to buy the remaining items that have been identified as non-healthcare items. If a retailer such as a wholesale club, discount store or on-line merchant does not have an IIAS in place, your transaction may be denied. 6. Does IIAS affect how I use my Benefits MasterCard for medical services? The IRS does not require locations such as doctor s offices, labs, hospitals to have IIAS in place and you can continue to use your Benefits MasterCard at these locations. 7. Does IIAS affect how I use my card to purchase prescription drugs at the pharmacy? Yes, pharmacies are required, by the IRS, to have IIAS in place in order for you to use your Benefits Card. 8. What is the benefit of IIAS? IIAS allows healthcare items to be purchased with the Benefits MasterCard and eliminates the need for you to send in receipts and documentation. 9. Do I choose debit or credit at the credit card terminal when I use my card? The Benefits MasterCard is swiped as a credit card at the terminal. 10. When should I save my receipts? You should always save a copy of your receipts, invoices, explanation of benefits (EOB) and bills for your records so that you will have a copy to submit in the event that we request supporting documentation or if audited. 11. Why would I be required to send supporting documentation for my Benefits Card transaction? The IRS requires supporting documentation for Flexible Spending Account expenses that are not validated through the IIAS system or by matching the expense to a health or dental plan copayment. 12. What type of supporting documentation or proof of services rendered am I required to submit? The IRS requires supporting documentation that includes the name of the provider, the date of service, and the type of service performed, the person treated and the amount of the service. For examples, an itemized statement or receipt from your provider, or an Explanation of Benefits from your insurance company for healthcare expenses are acceptable. The receipt that you signed for the purchase, balance forward statements or balance due statements are not acceptable forms of documentation because these types of documentation usually do not list the type of service performed or the name of the product. Proof of services rendered could include a provider statement or insurance Explanation of Benefits. Basically, anything created on provider letterhead or otherwise signed by the doctor letting us know that the patient is continuing to be seen for treatment. When you let the provider know that you have a Flexible Spending Account, they have a special form or receipt that they can give you. 13. How soon do I have to send in my documentation and what will happen if I don t send it in? If you do not submit your documentation to BenefitHelp Solution within 30 days of our request, we will send you a second request letter. If you still do not send in your supporting documentation, you will receive a final notice and your Benefits MasterCard will be deactivated until we receive the requested documentation.

4 14. Can I use my Benefits Card to pay for eligible over-the-counter (OTC) medicines and products? Yes you may purchase OTC items with your Benefits Card until December 31, 2010 at participating IIAS Retailer. Vitamins and herbal supplements will require a physician s letter stating the medical condition that is being treated. Effective January 1, 2011 over the counter (OTC) drugs, medicines and biologicals will no longer be eligible without a directive from a provider. You will not be able to use your Benefits MasterCard to purchase these items. 15. I received a statement from a provider for a service that was incurred last plan year. Can I use my Benefits MasterCard to pay for this bill? The Benefits Card can only pay for services incurred in the current plan year. You will be required to refund your account if you use the Benefits Card to pay for a service that was incurred in the previous plan year. 16. Can I use my Benefits MasterCard to pre-pay my provider for services? The service must have been incurred on or before the payment date and the service must have been incurred within the current plan year. Contact BenefitHelp Solutions at or concerning IRS regulations and special rules for orthodontia services. You may also use your card to pay for office visit co-pays. 17. Can I use my Benefits MasterCard to pay for Health Insurance premiums? No. Health Insurance premiums are not reimbursable through a Flexible Spending Account. 18. What happens if I accidentally use my card for an ineligible expense? You will receive a letter from BenefitHelp Solutions for the transaction requesting supporting documentation. If the transaction was for an ineligible expense, you will either be required to refund your account by check or submit a claim that you have not paid with your Benefits MasterCard. The eligible manual claim will be used to offset the ineligible Benefits MasterCard transaction by altering the reimbursable amount of the manual claim. Instead of reimbursing the entire eligible amount of the manual claim, you will only receive reimbursement once the balance due on an account is wiped out. The IRS does not allow you to use pretax dollars to pay for ineligible expenses. Please call us to report an accidental use. 19. Do I have to use my Benefits MasterCard for all transactions or can I still pay for the expense out of my own pocket and request reimbursement with a claim form? The Benefits Card is optional. You may pay for your expenses and submit them for reimbursement at any time. 20. Does the Benefits MasterCard work at my daycare center? The Benefits MasterCard does not work for daycare expenses. To use your Flexible Spending Account plan for daycare expenses you will need to pay for the expense at the daycare provider and then submit a request for reimbursement with a claim form to BenefitHelp Solutions. Claim forms can be found on our website at under FSA members or you can get one from your Human Resources department. 21. What happens to my Benefits MasterCard if I have a name change? You will need to notify your employer of your name change and submit a written request to BenefitHelp Solutions. Your Benefits MasterCard will be deactivated and cannot be used until your new card is received. 22. What do I do with my card once I have used all of my available funds? Your Benefits MasterCard is valid until the expiration date on the front of the card. You will be able to use the card again next year when you re-enroll in the plan. 23. Can I check my account and transactions on line? You can review your account balances and transactions by going to The first time you log-on, you will be asked to set up a sign-on and password. 24. What if my card is lost or stolen? The cardholder should notify BenefitHelp Solutions immediately upon learning of a lost or stolen card or a fraudulent transaction. BenefitHelp Solutions will inactivate the card immediately. You, the cardholder, must file a claim within 110 days of the fraudulent transaction. If notification is received timely your liability will be zero. Late notification will result in your liability for funds used fraudulently. Contact BenefitHelp Solutions immediately if your card is lost or stolen. For questions about your Benefits MasterCard or your Flexible Spending Account, contact BenefitHelp Solutions at or or [email protected].

5 SIGIS PREPARES TO MODIFY QUALIFIED ITEMS LIST IN RESPONSE TO HEALTH CARE REFORM In March, President Obama signed the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively "the Act"). The Act includes a number of modifications to employee benefit programs. One provision that will affect employee participants beginning January 1, 2011 is the requirement for over-the-counter (OTC) drugs, medicines and biologicals to be accompanied by a physician's prescription in order to be reimbursed under health flexible spending accounts (FSAs), health reimbursement arrangements (HRAs) and health savings accounts (HSAs). SIGIS, the special interest groups for IIAS Standards (Inventory Information Approval System), will be updating the eligible products criteria to reflect movement of OTC drugs medicines and biologicals items from the Eligible to Dual Purpose category. Over-the-counter medicines, drugs and biological treatments are about 35 percent of the current SIGIS list. OTC drugs, medicines and biologicals remain eligible with a directive from a provider. Below is a summary of this change and how it will impact plans and the participants' experience. CHANGES TO OVER-THE-COUNTER ELIGIBILITY FOR REIMBURSEMENT Under the Act, OTC drugs, medicines and biologicals will continue to be eligible for reimbursement as long as the request is accompanied by a doctor's prescription. This means items such as cough medicines, pain relievers, acid controllers, and diaper rash ointment will now require a doctor's prescription to be submitted along with the reimbursement request. Insulin and other OTC items, such as band-aids, will continue to be eligible without a prescription. Since this change applies to all expenses incurred on or after January 1, 2011, it will affect all plans and participants at the same time, regardless of the plan year. OTC drug expenses incurred on or after January 1, 2011 will require a doctor's prescription in order to be reimbursed under a health FSA, HRA or HSA. Expenses incurred prior to January 1, 2011 will not. Example: for a calendar year plan with a claim-it-by date of March 31, 2011, an OTC drug purchased on December 31, 2010, could be submitted before a plan's claim-it-by date of March 31, 2011, and still be reimbursed without a prescription. This provision will also impact the use of all heath care debit cards. Beginning January 1, 2011, merchants who are IIAS certified will need to modify the list of items eligible for payment. The list will be shorter; this is because of the doctor's prescription requirement. With the shorter list, fewer purchases will be authorized and auto substantiated at the point-of-sale. Customer Service: or

6 Purchases of OTC drugs, medicines and biologicals will require another form of payment and then the employee can submit a claim or request for reimbursement along with the doctor's prescription for the OTC drug, medicine or biological purchased. The following categories of items will require a doctor's prescription and thus, cannot be purchased using a Benefits Card: Acid Controllers Allergy & Sinus Antibiotic Products Anti-Diarrheals Anti-Gas Anti-Itch & Insect Bite Anti-parasitic Treatments Baby Rash Ointments/Creams Cold Sore Remedies Cough, Cold & Flu Digestive Aids Feminine Anti-Fungal/Anti-Itch Hemorrhoidal Preps Laxatives Motion Sickness Pain Relief Respiratory Treatments Sleep Aids & Sedatives Stomach Remedies The following are examples of some of the OTC items that will remain available without a doctor's prescription: Band Aids Birth Control Braces & Supports Catheters Contact Lens Supplies & Solutions Denture Adhesives Diagnostic Tests & Monitors Elastic Bandages & Wraps First Aid Supplies Insulin & Diabetic Supplies Ostomy Products Reading Glasses Wheelchairs, Walkers, Canes Please contact BenefitHelp Solutions if you have any questions. Customer Service: or

7 Dependent Care Account Program Questions and Answers Q. Are Pre-kindergarten programs and Day Camp expenses eligible for reimbursements? A. Yes. The IRS has clarified that pre-kindergarten programs such as Preschool and Day Camp expenses may be eligible, even though the underlying theme of the program is educational or recreational in nature. The deposits and application fees for pre-school and day camps that are attended by the dependent may be eligible for reimbursement, even if these costs are not directly related to the actual cost of care for the qualified individual at the time of payment. Q. My day care provider picks my children up from school and charges me a transportation fee. Is this fee a covered expense? A. Yes. The cost of transportation furnished by day care providers may be an eligible expense. Q. I do not always work a full week or the full month but I pay my day care provider in advance for the full month. Can I submit the entire month s day care charges for reimbursement? A. Yes. The IRS has also made it easier for taxpayers who pay Dependent Care expenses on a weekly, monthly (or longer) basis, with short term absences such as vacations or minor illness allowable as an eligible daycare expenses. Even tax payers who work part-time and pay daycare expenses on a weekly, monthly (or longer) basis can now include days they did not actually work as eligible expenses. Q. How much can I contribute to my Dependent Care Account? A. Employees may elect to reduce their salary by a maximum of $5,000 if married and filing your income tax jointly with your spouse or if single; or $2,500 if married and filing your income tax separately from your spouse. Q. What is the definition of an eligible dependent under the Dependent Care account? A. An eligible dependent includes a child under age 13, or a spouse or parent who is physically or mentally incapable of caring for himself or herself, for whom you are entitled to claim an exemption on your Federal income tax return. Q. My day care provider requires that I pay for services in advance. I have to pay at the beginning of the month for the entire month. When can I get reimbursed for these expenses? A. Reimbursement may only be paid for services already provided, and is limited to the amount actually withheld from your payroll or the accrued balance in your account. See below for faster reimbursement. Q. How do I submit a day care claim? A. You can use the online filing form or print a form from our web site or use the form in your packet and send it with the a receipt showing the name and amount paid to the day care provider, their social security number or taxpayer identification number, and the dates of service. You may submit the claim by fax, mail, or by scanning and submitting via our web site. Q. How can I get reimbursed faster than monthly? A. To expedite the release of the reimbursement, you may want to submit your request on a weekly or bi-weekly basis. Since you cannot be reimbursed until all dates of services have been rendered, by providing receipts weekly or bi-weekly basis, instead of monthly, you will receive your reimbursements faster. If you prefer, you may submit your request monthly, but attach the breakdown of dates of service on your receipts and on the claim form.

8 Q. Can you give me an example of how reimbursement works? Monthly Payment Example: Your daycare charges $800 per month and the dates of service are June 1 through June 30. You cannot be reimbursed until the following month. Reimbursements may only be made for services already provided, and is limited to the amount actually withheld from your payroll or the accrued balance in your account. You have elected $ per payroll with an annual election of $3, $ monthly daycare cost for June $ balance in your DCA and reimbursable to you $ balance remaining on your daycare claim The DCA will reimburse you $300 on the first check run in July and the balance will be issued as your account balance allows. You will not need to submit another claim until this claim has been reimbursed in full. Weekly Payment Example: Your daycare charges $800 per month and you pay it monthly, but you ask the daycare provider for four receipts ($200 each). Itemize the weekly breakdown on your dependent care claim form and submit it for reimbursement. You will receive your reimbursement on a weekly basis, limited to the balance in your account.

9 FSA Healthcare Account Reimburse Me Claim Form Fax: Submit online at Ph: or PO Box Portland, OR DO NOT USE A FAX COVER SHEET ACCOUNT HOLDER INFORMATION Member ID: Phone #: - - Name: Address: Member ID or last four digits of Social Security Number (not required) Last First New Address? YES Street Apt. Address: City State Zip Employer Name: Group #: (if known) CLAIMS FOR OUT-OF-POCKET EXPENSES INCOMPLETE FIELDS MAY RESULT IN YOUR CLAIM BEING DENIED / / $,. 1 Name of Dependent / Self Service Date (MM/DD/YY) Out-of-Pocket Cost Name of Provider / Merchant / / $,. 2 Name of Dependent / Self Service Date (MM/DD/YY) Out-of-Pocket Cost Name of Provider / Merchant / / $,. 3 Name of Dependent / Self Service Date (MM/DD/YY) Out-of-Pocket Cost Name of Provider / Merchant MORE EXPENSES? Complete another form. $,. YOU MUST ATTACH APPROPRIATE PROOF OF SERVICE FOR EACH AMOUNT ABOVE. TOTAL THIS FORM To submit healthcare or dental expenses, attach supporting documentation that includes the date of service, name of provider, the service performed and amount of the charge(s). An Explanation of Benefits from your insurance company or an itemized billing statement or receipt from your provider is an acceptable form of documentation. Canceled checks, credit card receipts/statements or balance forward or balance due statements are not IRS acceptable. I request reimbursement from my Flexible Spending Account for the listed expenses paid or to be paid by me. I certify these expenses are not covered or reimbursable from any other source, nor will I seek reimbursement for these expenses from any other source and that the expense is not for cosmetic purposes. I understand that I cannot use expenses reimbursed through the healthcare account as tax deductions when filing income tax returns. I further certify that the expenses submitted on this claim are for myself and/or my qualified tax dependents as defined under Internal Revenue Code Section 152 (as amended by the Working Families Tax Relief Act of 2004). Account Holder Signature: Date: Total Number of Pages: Signature of spouse or dependents is not acceptable. 210-ClaimHCA (10/09)

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11 Dependent Care Account Reimburse Me Claim Form Fax: Submit online at Ph: or PO Box Portland, OR DO NOT USE A FAX COVER SHEET ACCOUNT HOLDER INFORMATION Member ID: Phone #: - - Member ID or last four digits of Social Security Number (not required) Name: Address: Last Street First Apt. New Address? YES Address: City State Zip Employer Name: Group #: (if known) CLAIMS FOR OUT-OF-POCKET EXPENSES INCOMPLETE FIELDS MAY RESULT IN YOUR CLAIM BEING DENIED 1 / / $,. Name of Dependent DOB/Age Service Start Date (MM/DD/YY) Out-of-Pocket Cost Name of Provider / / Service End Date (MM/DD/YY) Provider s SSN or Tax ID# Provider s Signature: Date: Certifies services provided. Not required. Replaces need for receipt or other proof of service. 2 / / $,. Name of Dependent DOB/Age Service Start Date (MM/DD/YY) Out-of-Pocket Cost Name of Provider / / Service End Date (MM/DD/YY) Provider s SSN or Tax ID# Provider s Signature: Date: Certifies services provided. Not required. Replaces need for receipt or other proof of service. MORE EXPENSES? Complete another form. To submit dependent care expenses, attach documentation that includes the date(s) of service, name of provider, the tax ID# or social security number, who the care was for and the amount of the charge(s) or have your provider sign. Canceled checks, credit card receipts/statements or balance forward or balance due statements are not IRS acceptable. $,. TOTAL THIS FORM I request reimbursement from my Flexible Spending Account for the above listed expenses paid or to be paid by me. I certify these expenses are not covered or reimbursable from any other source, nor will I seek reimbursement for these expenses from any other source. I understand that I cannot use expenses reimbursed through the dependent care account as a tax credit when filing income tax returns. I further certify that the expenses submitted on this claim are for myself and/or my qualified tax dependents as defined under Internal Revenue Code Section 152 (as amended by the Working Families Tax Relief Act of 2004). Account Holder Signature: Date: Total Number of Pages: Signature of spouse or dependents is not acceptable. 211-ClaimDCA (05/10)

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