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Myfbmc com forms 2025

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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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Click ‘Get Form’ to open the myfbmc com Claim Form in the editor.
Begin by filling out the Personal Data section. Use black ink only and ensure all fields are completed, including your name, home phone, address, and FBMC ID number.
Indicate if this is a new address by checking the appropriate box. This helps maintain accurate records.
Read and agree to the certification statements provided. Your signature and date are required to process your claim.
Select your payment type by placing a check mark in the relevant box and fill in the claim amount for each applicable expense.
Complete the Medical FSA or HRA section with details of services received, including service dates, provider information, and amounts owed.
If applicable, fill out the Dependent Care FSA section with similar details for childcare services. Ensure you have documentation ready for submission.

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Versions	Form popularity	Fillable & printable
2011	4.8 Satisfied (148 Votes)
2008	4 Satisfied (41 Votes)

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