IMPORTANT INSTRUCTIONS AND INFORMATION
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- This Reimbursement Request form must be signed by you and your care provider(s), or
you may attach separate receipts from your service providers that list the name, address and tax ID number (or SS#) of the provider. Requests will not be processed without this information.
- Reimbursement can only be made for those expenses resulting from services that occur during the Plan Year.
- Any unused year-end balance in your DCAAccount may not be carried over to the next plan year. The funds will be forfeited and returned to NYS, as your employer.
- The deadline to incur expenses is the last day of the month of the plan year. However, NYS allows a 90-day runout period after the end of the Plan Year, during which time you may submit reimbursement requests for services incurred during the previous Plan Year. Reimbursement Requests postmarked later than March 31st will not be processed.
- If dates of service for which you are seeking reimbursement begin in one Plan Year and end in the next Plan Year, a Reimbursement Request form for each year is required.
- Be sure to sign and date SECTION C.
- Call 1-800-358-7202 (option 1) for Customer Service, Fringe Benefits Management Company, Plan Administrator for the Dependent Care Advantage Account Program.
- Mail or fax to:
P.O. Box 14766
Lexington KY 40512-4766
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TRIM YOUR DEPENDENT CARE EXPENSES—FAX FREE!