YTCD - Reimbursement Request

FLEX Reimbursement

Request Form
PLEASE READ BEFORE SUBMITTING
- Employees seeking reimbursement for qualified FLEX expenses, must provide all required information below, prior ro receiving reimbursement.
- To expedite processing, please provide relevant receipts and payment vouchers for the qualified expenses you are seeking reimbursment for.
- Requests will be reviewed and processed once a week and will be paid on the 15th and last day of each month.
If you need additional information, need help completing this form or have questions about your reimbursement, please feel free to reach out to bookkeeper@ytc.edu or 303-536-1803 x 1.
Account Holder Information
Name*

First NameLast Name
E-mail Address*
Your E-mail Address
Phone Number*
Please enter a valid phone number.
Expense Description
Provider Name*
Service Date*

MonthDayYear
Date
Patient Name*
Relationship to Employee*
Type of Service*
Out-of-Pocket Cost*
Would you like to add another instance?*

YesNo
Provider Name*
Service Date*

MonthDayYear
Date
Patient Name*
Relationship to Employee*
Type of Service*
Out-of-Pocket Cost*
Would you like to add another instance?*

YesNo
Provider Name*
Service Date*

MonthDayYear
Date
Patient Name*
Relationship to Employee*
Type of Service*
Out-of-Pocket Cost*
Would you like to add another instance?*

YesNo
Provider Name*
Service Date*

MonthDayYear
Date
Patient Name*
Relationship to Employee*
Type of Service*
Out-of-Pocket Cost*
Total Reimbursement
Receipt(s)/Payment Voucher
I have copies of the relevant receipts for this reimbursement, I would like to*

Upload them from my phone or computerTake a picture directly from this form
Please upload a copy of your receipt(s) below*

If you don't have an actual receipt available, please upload a copy of the charge, email or etc.
Cancelof
Take a photo of your receipt*
Reimbursement Information
Do we have your direct deposit information on file?*

Yes, please use my direct deposit information on file, for my reimbursementI would like to enter or update my direct deposit information
Routing Number*
Account Number*
Sign & Submit
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

FLEX Reimbursement

Account Holder Information

Expense Description

Receipt(s)/Payment Voucher

Reimbursement Information

Sign & Submit