Fillable DEPENDENT CARE ADVANTAGE ACCOUNT REIMBURSEMENT REQUEST FORM - flexspend ny

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NEW YORK STATE FLEX SPENDING ACCOUNT A STATE EMPLOYEE BENEFIT THAT PUTS MONEY IN YOUR POCKET DEPENDENT CARE ADVANTAGE ACCOUNT REIMBURSEMENT REQUEST FORM PLEASE READ THE INSTRUCTIONS BELOW BEFORE COMPLETING THIS FORM. A NAME ADDRESS CITY SOCIAL SECURITY NUMBER STATE ZIP LIST THE NAMES AND ADDRESSES OF THE PROVIDER(S)1 Or SERVICE FOR WHICH YOU ARE APPLYING FOR REIMBURSEMENT PROVIDER SS# or FEDERAL TAX ID NUMBER...
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