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URBANDALE

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Fillable DCAp Claim Form - urbandale

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DEPENDENT CARE CLAIM FORM Instead of completing this form you may file your claim online at www.GenesisBenefits.net. You may also track your payments, view plan balances and see claim history online anytime. Please comply with the following instructions to file your claim for reimbursement. Failure to follow these instructions will delay processing of your claim and may result in your claim being returned to you. Additional information regarding allowable expenses is provided on the reverse of this form More


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eFax GenesisBenefits 11Claim-Form-Dep-Care itemization 2010 2011 permissibility SSN orFAX CustomerCareGenesisBenefits reimbursable FSA allowable substantiation Login reimbursement audits reimbursed MN ineligible itemized notation applicable taxation IRS C


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