Transcription of FSA Dependent Care Request for Reimbursement
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FSA Dependent Care Request for Reimbursement
Central Ohio Technical College - Office of Human Resources Page 1 of 2 FSA Dependent care Request for Reimbursement Form Revised 12/5/08 FSA Dependent care Request for Reimbursement Important instructions please read prior to completing this form: 1. Total of the Amount to be Reimbursed must be $25 or greater. 2. To prevent delays in processing, complete all requested information. 3. Faxed copies of the completed form are not acceptable. 4. Staple appropriate bill(s) or receipt(s) to this form or in lieu of these, original provider signature may be used.
FSA – Dependent Care Request for Reimbursement Form Revised 12/5/08 Instructions for Dependent Care FSA Reimbursement Complete the front of this form in its entirety, with original signature(s) only.
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