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The document is a claim form for Flexible Spending Accounts (FSA) and Health Reimbursement Arrangements (HRA), requiring personal data and certification of understanding regarding eligible expenses. It outlines the process for reimbursement, necessary documentation, and specific requirements for medical and dependent care claims. Users must complete the form in black ink, attach original receipts, and retain copies for their records.

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2011	4.8 Satisfied (148 Votes)
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