Southern Administrators & Benefit Consultants, Inc.
Debit Card Expense Validation Form
(Submit separate request forms for each plan year.)
SSN (or 9-digit Employee No.):
numbers only, no hyphens
Employee Name will automatically populate based on employee id.
Company Name will automatically populate based on employee id.
In-Office Check Pickup:
Check here to indicate that you will pick up your reimbursement check at the
offices of Southern Administrators & Benefit Consultants in Ridgeland, MS.
Dependent Day Care Expenses Total:
Unreimbursed Medical Expenses Total:
An Explanation of Benefits from your insurance carrier is
always the preferred receipt, and may be required.
HRA Expenses Total:
Employer Supplement Plan (EOB Required)
Please upload only .jpg, .gif, .png, or .pdf images.
Limit 20 files and 8mb per file attachment!
+ Add Another Receipt
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.
Please enter your SSN or 9-digit Employee No. as your signature, with no punctuation.
Change of Status
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