HomeMy WebLinkAboutSUB200600016 Review Comments Final Plat 2006-03-06County of Albemarle
Finance Administration Department
Beneplus Reimbursement Accounts
CLAIM FORM
PLAN YEAR
Requests should be
placed in sealed envelope
marked "Beneplus —
Finance Administration
Office"
Instructions:
1. Attach copies of bills or statements showing the date the expense was incurred along with proof of
payment (such as canceled checks or receipts).
2. Double -check your figures. Make sure the amount(s) on the claim form correspond to the amount(s) on
the receipts submitted.
3. Be sure to place the amount(s) on the appropriate line(s) (i.e., medical and dental under Health Care,
childcare under Dependent Care).
4. Please retain a copy of this claim form for your records. If ordinal receipts /proof of payment is attached
they will not be returned to you. Retain originals for your records.
5. Submit completed reimbursement request form along with the appropriate documentation supporting your
request (as indicated in #1 above) along with one additional copy of the reimbursement request form
(without documentation) to the Finance Administration Office. To protect your privacy requests
should be sealed in an envelope addressed: `Beneplus" Finance Administration Office.
6. Requests received by the 20th of the month are reimbursed at the end of the month.
Name:
School/Department:
Home Address:
Social Security No:
(PLEASE PRINT)
❑ Check if this is a new address
I request reimbursement for the following legitimate expense(s) and I certify that these expenses are not
eligible for coverage or reimbursement by any insurance policy or policies, whether paid for by the County of
Albemarle or individually.
TYPE OF SERVICE:
Verified by:
Health Care Expenses $
Dependent Care Expenses $
(EMPLOYEE SIGNATURE)
(PLAN ADMINISTRATOR)
BENEPLUS REIMBURSEMENT.DOC (06/2003) Recycle previous copies
TOTAL: $ 0.00
(DATE)
(DATE)