Flexfacts phone reimbursement form 2025

1. Click ‘Get Form’ to open the flexfacts phone reimbursement form in the editor.
2. Begin by filling out your personal information. Enter your full name, employer, social security number, phone number, and email address in the designated fields.
3. If your address has changed, provide the new address along with the city, state, and zip code.
4. In the Claim Information section, specify the type of expense (Medical FSA, Dependent Care FSA, HRA, Transit or Parking) and enter the corresponding amounts for each type of expense listed.
5. For dependent care or transit certification, complete the provider's name and service start and end dates. If applicable, include the provider's tax ID number and obtain their signature.
6. Finally, sign and date the form to confirm that you agree to have your account reduced by the requested amount and that these expenses have not been reimbursed elsewhere.

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