• Services must have been incurred to receive reimbursement. You may not request reimbursement until you have received the service, regardless of when you pay for it.
  • Reimbursement can only be made for expenses for services that have been provided within the plan year.
  • According to the IRS regulations, any unused year-end balance in your spending account may not be carried over to the next plan year. Monies must be forfeited to New York State and will be used to defray administrative costs of the NYS Flex Spending Account program.
  • If dates of service for which you are seeking reimbursement begin in one plan year and end in the next plan year, a separate Reimbursement Request form is required for each year.
  • New York State allows a 90-day runout period after the end of the plan year. During this time you may submit Reimbursement Requests for services incurred during the plan year.
  • Be sure to sign and date SECTION C.


  • According to the IRS regulations, dependent care reimbursement requests cannot be processed without receipts from the provider showing the name, address, and tax ID number (or social security number) of the provider. Beginning and ending dates of service are required on the dependent care receipt. If the receipt is from an individual care provider you MUST have the provider sign the above-mentioned receipt, or you may use the Reimbursement Request form as a receipt if SECTION B is co-signed by your care provider.
  • Fringe Benefits Management Company will be unable to authorize payment until after the last date of service for which you are requesting reimbursement.
  • Copies of canceled checks are not sufficient receipts for IRS purposes.
  • A qualified dependent is your dependent under age 13, your dependent who is physically or mentally incapable of self-care, or your spouse who is physically or mentally unable to care for himself or herself. According to the IRS, physical or mental incapacity is not being able to dress, clean, or feed oneself.
  • Payments for dependent care cannot be made to someone you or your spouse claim as a dependent. If the person you make payments to is your child, he or she must be age 19 or older by the end of the year.
  • Overnight camp expenses do not qualify for dependent day care reimbursement.
  • Tuition for Kindergarten or higher is not eligible for reimbursement. However, if tuition paid for Kindergarten or higher includes eligible expenses for before and after-school care, you may be reimbursed for that portion of the tuition providing the before and after-school care.

Fringe Benefits Management Company, A Division of WageWorks
P.O. Box 14766
Lexington KY 40512-4766

Customer Service
1-800-358-7202 (option 1)