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Dependent Care Account Claim Form
DEPENDENT CARE ACCOUNT CLAIM FORM. A. ACCOUNT HOLDER INFORMATION -- COMPLETE FOR ALL CLAIMS (PLEASE PRINT CLEARLY). Employer Name: This claim applies to the
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UNIVERSAL CLAIM FORM
I am only submitting for reimbursement for eligible expenses that I incurred for myself or legal dependents. I docHub that I have not been nor will I be
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Reporting and Disclosure Guide for Employee Benefit Plans
Automatically to participants and pension plan beneficiaries receiving benefits within. 9 months after end of plan year, or 2 months after due date for filing
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