Flexible Spending Reimbursement Voucher Form

Home Phone Work Phone Unreimbursed Medical Expenses Dependent / Child Care Expenses (Office Visits, Co-Pays, Vision, Dental, etc.) Receipt must include Nature of Service, Date of Service, and Amount Prescription for item Nature of Service (Day Camps, Babysitters, Daycare Centers, etc.) Receipt must include Date of Service, Amount, and SS or Tax ID on file with PGP: Date(s) Amount Name of Day Care Provider SS or Description of Service Date(s) Tax ID Amount TOTAL Premium Expenses (Privately held insurance policies) Description of Service Dates of Service Amount 1 2 TOTAL This is to certify that I have incurred the expenses listed above for myself or qualifying dependents and that the expenses detailed above are eligible for reimbursement in accordance with applicable governmental rules and regulations for cafeteria plans..