+---------------+--------------------------------------+---------------+
| **MAIL        | #########                            | **FAX TO:**   |
| TO:           |                                      |               |
| **![](media/i | #########  Health/Dependent Care     | **PayFlex     |
| mage1.png){wi |                                      | Systems USA,  |
| dth="0.988194 | **Flexible Spending Accounts-FSA**   | Inc.**        |
| 4444444445in" |                                      |               |
| heig          | **Claim Form**                       | **(402)       |
| ht="0.5763888 |                                      | 231-4310**    |
| 888888888in"} |                                      |               |
|               |                                      | **(No Cover   |
| **PayFlex     |                                      | Page          |
| Systems USA,  |                                      | Required)**   |
| Inc.**        |                                      |               |
|               |                                      | **Page 1 of   |
| **P.O. Box    |                                      | \             |
| 3039**        |                                      | _\_\_\_\_\_** |
|               |                                      |               |
| **Omaha, NE   |                                      |               |
| 68103-3039**  |                                      |               |
|               |                                      |               |
| **(402)       |                                      |               |
| 345‑0666**    |                                      |               |
+---------------+--------------------------------------+---------------+

For additional information regarding eligible expenses and claim filing,
please visit our website at: **www.mypayflex.com**.

**Employee Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SSN \_\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_**

**Employer Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Note: To make an address change, please contact your employer
HR/Benefits. For security purposes, we cannot accept address changes
directly.

**Health Care Claims** (For you or your dependents) - For additional
information, please visit our website at: **www.mypayflex.com**.

**Covered by insurance** - Expenses for services or items must be
submitted to your insurance company *before* submitting for
reimbursement under your flexible spending account. When you receive the
**Explanation of Benefits Statement (EOB)** from your insurance company,
include a copy with this completed claim form. If you have a copay,
attach an itemized statement from your service provider. Do not submit
expenses previously paid for with your Flex Convenience® card.

**Not covered by insurance** - For services or items, submit an itemized
statement from the provider showing the provider's name and address,
patient name, date the service was provided, a description of the
service, and the amount charged along with this completed claim form.
Balance forward statements, cancelled checks, credit card receipts or
received-on-account statements are [not]{.underline} acceptable.
Orthodontia claims require an itemized statement/payment receipt, the
orthodontist's contract/payment agreement or monthly payment coupons.

**Prescription and over-the-counter** drugs and medicines require a
print-out of prescriptions from your pharmacy or must be clearly
identifiable on an itemized receipt. Quantities purchased must be
reasonably able to be consumed during the current plan year. Items for
maintaining general good health, cosmetic purposes and dietary
supplements are not eligible.

+-------+------------------+------+---+-------+------------------+-------+
| Date  | Type of Service  | Am   |   | Date  | Type of Service  | A     |
| of    | (Ex. --          | ount |   | of    | (Ex. --          | mount |
| Se    | Prescription,    |      |   | Se    | Prescription,    |       |
| rvice | O                | R    |   | rvice | O                | Requ  |
|       | ver-the-Counter, | eque |   |       | ver-the-Counter, | ested |
|       | Vision, Dental,  | sted |   |       | Vision, Dental,  |       |
|       | Hearing, Office  |      |   |       | Hearing, Office  |       |
|       | Visit, etc...)   |      |   |       | Visit, etc...)   |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       |                  |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       |                  |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       |                  |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       |                  |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       |                  |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       |                  |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       |                  |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       |                  |       |
+-------+------------------+------+---+-------+------------------+-------+
|       |                  |      |   |       | **Total**        | *     |
|       |                  |      |   |       |                  | *\$** |
+-------+------------------+------+---+-------+------------------+-------+

**Dependent Child or Adult Day Care Claims** - For additional
information, please visit our website at: **www.mypayflex.com**.

Complete this form and attach an itemized statement from your day care
provider or have your provider complete the information below. **IRS
regulations allow payment for services for an eligible dependent under
age 13 or otherwise meets the "Qualifying Person Test" and for services
that have already been provided, not for services to be provided in the
future. (**IRS regulations require you to report the provider's name,
address and Tax Identification Number (or Social Security Number) on
Form 2441 with your personal income tax return.) If your day care
provider completes and signs this form below, no other itemized
statement is necessary.

+--------+--------+---------------+-------------------------+--------+
| Exact  |        | # D           |                         | Amount |
| Dates  |        | ependent Name |                         |        |
| of     |        |               |                         | # Req  |
| S      |        |               |                         | uested |
| ervice |        |               |                         |        |
+--------+--------+---------------+-------------------------+--------+
| # From | To     |               |                         |        |
+--------+--------+---------------+-------------------------+--------+
| ###    |        |               |                         |        |
+--------+--------+---------------+-------------------------+--------+
|        |        |               |                         |        |
+--------+--------+---------------+-------------------------+--------+
|        |        |               |                         |        |
+--------+--------+---------------+-------------------------+--------+
|        |        |               |                         |        |
+--------+--------+---------------+-------------------------+--------+
|        |        | **Total**     |                         | **\$** |
+--------+--------+---------------+-------------------------+--------+
| ***Day |        |               | ***Day Care Provider    |        |
| Care   |        |               | Information:***         |        |
| Pr     |        |               |                         |        |
| ovider |        |               | ***Name                 |        |
| Inf    |        |               | \_\_\                   |        |
| ormati |        |               | _\_\_\_\_\_\_\_\_\_\_\_ |        |
| on:*** |        |               | \_\_\_\_\_\_\_\_\_\_\_\ |        |
|        |        |               | _\_\_\_\_\_\_\_\_\_\_\_ |        |
| *      |        |               | \_\_\_\_\_\_\_\_\_\_*** |        |
| **Name |        |               |                         |        |
| \      |        |               | ***Provider***          |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               | ***Signatur             |        |
| _\_\_\ |        |               | e\_\_\_\_\_\_\_\_\_\_\_ |        |
| _\_\_\ |        |               | \_\_\_\_\_\_\_\_\_\_\_\ |        |
| _\_\_\ |        |               | _\_\_\_\_\_\_\_\_\_\_\_ |        |
| _\_\_\ |        |               | \_\_\_\_\_\_\_\_\_\_*** |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_*** |        |               |                         |        |
|        |        |               |                         |        |
| **     |        |               |                         |        |
| *Provi |        |               |                         |        |
| der*** |        |               |                         |        |
|        |        |               |                         |        |
| ***    |        |               |                         |        |
| Signat |        |               |                         |        |
| ure\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_\_\ |        |               |                         |        |
| _\_*** |        |               |                         |        |
+--------+--------+---------------+-------------------------+--------+

I certify that these eligible expenses have been incurred by me, my
spouse or eligible dependent and medical expenses are not for cosmetic
purposes but for the treatment of an illness, injury, trauma, or medical
condition. I understand that "incurred" means the service has been
provided that gave rise to the expense, regardless of when I am billed
or charged for, or pay for the service. The expenses have not been
reimbursed and I will not seek reimbursement elsewhere. I understand
that any amounts reimbursed may not be claimed on my or my spouse's
income tax returns. I have received and read the printed material
regarding the reimbursement accounts and understand all of the
provisions.

** **Employee Signature** **Date**

**\*\*\*\*\**Make copies for yourself, since these documents will not be
returned. If you fax your claim, keep the original*.\*\*\*\*\*** Rev.
9/2004