Flexible Benefit Plan Reimbursement ClaimForm

EmployeeName:

E-mail:

Phone:

Dependent Care ExpenseClaims
Name ofDependents / PeriodCoveredFromTo / Name, Address, and TaxpayerIdentificationNumber of ServiceProvider / AmountIncurred
Attach a receipt from your daycare provider, or include thedaycareprovider’ssignature. / Provider’sSignature:
Total Dependent Care ExpenseClaim* / $

*NOTE: The total amount claimed under the Plan for any coverage period must not exceed the lesser of your earned income for the Plan Year or the earned incomeofyour spouse. (If your spouse is either a full-time student or is incapable of taking care of himself or herself, then he or she is deemed to have monthly earnings of$200ifthereisone(1)childordependent,or$400iftherearetwo(2)ormore.)NopaymentmaybemadeunderthePlan;iftheserviceproviderisyourdependentforfederal income tax purposes; or is your child or stepchild and is under age19.

Unreimbursed Medical ExpenseClaims
DateExpenseIncurred / Name of ServiceProvider / ExpenseDescription / Person forWhomExpenseIncurred / NetAmount
Attach appropriate receipt(s) and submit with this claimform. / Total Medical Care ExpenseClaim / $

ReadCarefully:TheundersignedparticipantinthePlancertifiesthatallservicesforwhichreimbursementorpaymentisclaimedbysubmissionofthisformwereprovidedduringaperiodwhiletheundersignedwascoveredundertheCompany’sCafeteriaPlanwithrespecttosuchexpensesandthatthemedicalexpenseshavenot been reimbursed or are not reimbursable under any other health plan coverage. The undersigned fully understands that he or she alone is fully responsible forthesufficiency,accuracy,andveracityofallinformationrelatingtothisclaimwhichisprovidedbytheundersigned,andthatunlessanexpenseforwhichpaymentorreimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes including federal, state, or city incometaxon amounts paid from the Plan which relate to suchexpense.

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Employee’sSignatureDate

ContactInfo:

Name:AprilTennell

Phone:(800) 824-5034 (TollFree)

(918) 335-0387 (Bartlesville,OK)

FaxClaims:(866)513-9681

EmailClaims:

MailClaims:300 SE Frank Phillips Blvd. Suite200

Bartlesville, OK74003

Website: on Flex AccountLogin)

To expedite youclaim:

  • Provide all appropriateinformation.
  • Review the Total Dependent Care and Total Medical Care Expense Amounts beforeprinting.