Clone of YTCD - FLEX Reimbursement Request

Dependent Care FLEX Reimbursement

Request Form
PLEASE READ BEFORE SUBMITTING

Employees requesting reimbursement for qualified Flexible Spending Account (FSA) expenses must complete this form and provide all required information before reimbursement can be processed.

To help expedite processing, please upload all applicable receipts, invoices, payment vouchers, or other supporting documentation related to the qualified expenses for which you are requesting reimbursement.

Please Note:
- Incomplete requests or missing documentation may delay processing.
- Reimbursement requests are reviewed and processed weekly.
- Approved reimbursements are issued on the 15th and last business day of each month.
- Reimbursements are limited to the amount currently available in your Dependent Care FSA account at the time the claim is processed.
If you have questions about completing this form, eligible expenses, or the status of your reimbursement, please contact the Bookkeeper at bookkeeper@ytc.edu or call 303-536-1803 ext. 1.
Account Holder Information
Name

First NameLast Name
E-mail Address
Your E-mail Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Expense Description
Provider Name
Provider’s Tax Identification Number (EIN) orSocial Security Number (SSN)
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Date

MonthDayYear
Date
Name of the child(ren)receiving care
Relationship to Employee
Type of Service
Out-of-Pocket Cost
Description of the services
Would you like to add another instance?
Provider Name
Provider’s Tax Identification Number (EIN) orSocial Security Number (SSN)
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Date

MonthDayYear
Date
Name of the child(ren)receiving care
Relationship to Employee
Type of Service
Out-of-Pocket Cost
Would you like to add another instance?
Provider Name
Provider’s Tax Identification Number (EIN) orSocial Security Number (SSN)
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Date

MonthDayYear
Date
Name of the child(ren)receiving care
Relationship to Employee
Type of Service
Out-of-Pocket Cost
Would you like to add another instance?
Provider Name
Provider’s Tax Identification Number (EIN) orSocial Security Number (SSN)
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Date

MonthDayYear
Date
Name of the child(ren)receiving care
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, which include the name of the dependent care provider, the provider's address, Tax Identification Number (EIN) or Social Security Number (SSN), the dates care was provided, the name of the child(ren) receiving care, the amount charged for the services, a description of the services provided, and the provider's signature. I would like to
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?
Routing Number
Account Number
Sign & Submit
Signature
Today's Date

MonthDayYear
Date
Should be Empty:

Dependent Care FLEX Reimbursement

PLEASE READ BEFORE SUBMITTING

Account Holder Information

Expense Description

Receipt(s)/Payment Voucher

Reimbursement Information

Sign & Submit