Limited Purpose FSA Card Expense Substantiation Form: Fill out & sign online

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Limited Purpose FSA Card Expense Substantiation Form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click 'Get Form' to open the Limited Purpose FSA Card Expense Substantiation Form in the editor.
Begin by completing all Employee Information fields. Enter your 10-digit FlexID, name in ALL CAPITAL letters, employer's name, mailing address, and a daytime phone number.
Next, fill out the Purchase Information section. Include one purchase per box, noting the purchase date, total amount, type of service (dental, vision), and merchant name. Ensure that this information matches your receipts.
If you cannot provide a qualified receipt for any purchase, check the appropriate box indicating this on the form. Remember that doing so will deactivate your card until you submit a new eligible expense claim.
Finally, sign and date your form to certify that all expenses are valid and have not been reimbursed elsewhere. This step is crucial for processing your submission.

Start using our platform today to easily complete your Limited Purpose FSA Card Expense Substantiation Form for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Contact us

What is a substantiation on a FSA debit card?

Auto-substantiation occurs when your purchase can be verified as eligible at the point-of-sale. For example, a prescription at a pharmacy or a purchase on FSAStore.com. This accounts for 85% of all debit card purchases. Manual Substantiation occurs when your card swipe does not auto-substantiate.

What are the IRS rules for substantiation of FSA?

What does the IRS require for FSA substantiation? Date service was received or purchase was made. Description of service or item purchased. Dollar amount. Provider or store name.

What is FSA substantiation?

How FSA substantiation works. FSA funds can be used for eligible healthcare expenses, but every transaction must be properly substantiatedmeaning documented and approved. The IRS requires this step to ensure that FSA dollars are only spent on eligible medical, dental, and vision expenses.

Is there a tax form for limited purpose FSA?

There is no 1099-SA form or other tax statement for the Flexible Spending Account (FSA), which is different from the Health Savings Account (HSA). FSA funds are already tax-free and not needed for tax purposes. An FSA allows you to contribute pre-tax dollars from your salary.

What is a substantiation request?

Substantiation is the process of submitting and verifying submitted documentation to prove a participants purchase was eligible under their employers plan rules.