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Title:	Claim Form.pdf
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Handle:	Document-2724
Owner:	Site Administrator (User-2, admin:DocuShare)^DS
Create Date:	Thursday, April 10, 2003 09:40:37 PM CDT
Modified Date:	Thursday, March 26, 2015 05:00:06 PM CDT
Modified By:	Site Administrator (User-2, admin:DocuShare)^DS
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Abstract:	Health Care Benefits1. Complete the entire form, listing each expense. EMPLOYEE INFORMATION Employer Name__________________________________________ Social Security No. I certify that I am claiming reimbursement only for eligible expenses incurred during the applicable plan year for qualifying individuals. Employee Signature: Date:______________
Add Versions:	Allowed
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Content Type:	Adobe Portable Document Format (.pdf) - application/pdf
File name:	Claim Form.pdf
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Size:	14424
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Ready for Declare:	No
Appears In:	Scanned images
Preferred Version:	Claim Form.pdf