SABC
Southern Administrators & Benefit Consultants, Inc.
Debit Card Expense Validation Form
Plan Year:
to
(Submit separate request forms for each plan year.)
SSN (or 9-digit Employee No.):
numbers only, no hyphens
Employee Name:
Employee Name will automatically populate based on employee id, if we have a record.
If not, you can enter your information manually.
Company Name:
Select One
Company Name will automatically populate based on employee id, if we have a record.
If not, you can enter your information manually.
Daytime Phone:
(
)
-
ext.
Email Address:
Attach Receipts
Please upload only image file types: .jpg, .gif, .png, or .pdf files.
Limit 20 files and 10Mb per file attachment!
Receipt Image:
Delete
+ Add Another Receipt
Limit 20
Claim Comments:
To the best of my knowledge and belief, my statements in this Request for Reimbursement are complete and true. I am claiming reimbursement only for eligible expenses incurred after the effective date of my participation in the plan and only for eligible family members. I certify that these expense(s) have not been previously reimbursed or are not reimbursable under any other health plan coverage, and will not be claimed as an income tax deduction. I authorize my Flexible Spending Account be reduced by the amount of eligible expenses requested.
Signed Date:
2024-04-20
Signature:
Please enter your SSN or 9-digit Employee No. as your signature, with no punctuation.
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