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Spending reimbursement form 2026

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Click ‘Get Form’ to open the spending reimbursement form in the editor.
Begin by filling out Section I, which includes your Employer and Employee Information. Enter your Employer Name, Group Number, and Employee details such as Name, SSN, and Contact Information.
In Section II, detail your Reimbursement Request. Attach all relevant receipts for expenses incurred. Specify the type of Health Flexible Spending Account (FSA) expenses along with the Date of Service and Amount for each category: Medical, Dental/Vision, RX, and OTC/Other.
For Dependent Care Assistance (DCA) Expenses, provide the necessary details including the Amount of Expense(s), Date of Service, and information about the dependent(s). Ensure you include the Provider's Tax ID Number and signature if required.
Finally, complete Section III by certifying that all provided information is accurate. Sign and date the form to confirm your request for reimbursement.

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