PLEASE READ THIS BEFORE SUBMITTING YOUR RETIREE …
Ford HRA Retiree Pay Me Back Claim Form Instructions WW-HRA-PMB-FORD-INST (Jun 2008) Page 3 of 3 Section 3 – Other Expenses X If you are requesting reimbursement for other out-of-pocket expenses that you have paid for such as co-pays, dental services, eligible over-the-counter items or other eligible expenses, please complete this section.
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