Flex Account Reimbursement Form - JW Terrill 2025

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4 out of 5

51 votes

The document is a FlexPay Request for Reimbursement form, which allows employees to claim reimbursement for eligible health care and dependent care expenses. It requires personal information from the employee, details of the expenses incurred, and specific documentation such as receipts and provider information. The form outlines the necessary steps for submission, including acceptable forms of proof and limitations on reimbursements.

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Versions	Form popularity	Fillable & printable
2017	4.6 Satisfied (51 Votes)
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