SABC

Southern Administrators & Benefit Consultants, Inc.

Debit Card Expense Validation Form

to
(Submit separate request forms for each plan year.)
numbers only, no hyphens
 Employee Name will automatically populate based on employee id, if we have a record.
If not, you can enter your information manually.

Company Name will automatically populate based on employee id, if we have a record.
If not, you can enter your information manually.
() - ext.


Attach Receipts


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Limit 20 files and 10Mb per file attachment!

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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: 2021-04-19
Please enter your SSN or 9-digit Employee No. as your signature, with no punctuation.

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