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Cagney Choice Fund Reimbursement Request Form Use this form to request payment from your: Health Reimbursement, Health Care Flexible Spending, Healthy Awards or Healthy Future Accounts. Please follow

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1. Read the instructions carefully: Before starting to fill out the form, it is important to thoroughly read the instructions provided. This will ensure that you understand the requirements and any specific details that need to be included.
2. Gather all necessary information: Take the time to collect all the required information that needs to be filled out on the form. This may include personal details, contact information, identification numbers, or any other relevant data.
3. Provide accurate and complete information: Ensure that all the information you provide on the form is accurate and complete. Double-check names, addresses, and other details to avoid any errors or discrepancies.
4. Follow the formatting guidelines: Pay attention to any specific formatting guidelines mentioned in the instructions. This could include using specific date formats, capitalizing certain letters, or providing information in a certain order.
5. Sign the form: Once you have completed filling out the form, it is necessary to sign it. Locate the designated signature field and sign your name exactly as it appears on any supporting documents or identification. If the form requires multiple signatures, ensure that all required parties have signed accordingly.

Who needs to fill out and sign the form:

1. Individuals applying for a specific service or benefit: Forms are often required for individuals who are applying for services or benefits, such as applying for a passport, driver's license, or government assistance. In these cases, the person seeking the service or benefit needs to fill out and sign the form.
2. Employees or job applicants: Forms are commonly used in the employment process, such as job applications, insurance enrollment forms, or tax-related documents. Employees or job applicants are responsible for filling out and signing these forms.
3. Individuals involved in legal or financial matters: Legal and financial matters often involve the completion of various forms. This could include signing contracts, power-of-attorney forms, loan applications, or tax forms. The individuals involved in these matters need to fill out and sign the relevant forms.

Remember, it is always best to consult the specific instructions provided with the form to ensure you are following the correct procedures and meeting all necessary requirements.

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The purpose of the form is to gather important information and validate the authenticity of the submission by requiring a signature.

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