June 3, 1996
INC. FSA - CLAIM VOUCHER
Braintree, MA 02184
(781) 848-8477 (Fax)
#: XXX -XX - _______
PHONE: ( )
UNREIMBURSED MEDICAL EXPENSES (Participants & Eligible Dependents -as defined by the IRS guidelines)
ITEMS (group similar items)
DATE OF SERVICE
DEPENDENT/CHILD CARE EXPENSES (daycare)
OTHER ACCOUNT EXPENSES (e.g. COBRA)
TRANSPORTATION ACCOUNT EXPENSES (For Participants Enrolled in Qualified Parking/Transit Plan ONLY)
PARKING (IRS Monthly max $230)
All medical claims submitted require copies of bills/statements/receipts showing date and type of service. (No cancelled checks/credit
card receipts). All claims must be received 2 days prior to claim payment day. Direct deposit payments are processed weekly
(Wednesday). Checks are processed at least twice a month (every other Wednesday). Please allow 3 business days to receive your
check. Minimum payment is $20.00.
This is to certify that I have incurred the expenses listed above that qualify for reimbursement under my employer’s Cafeteria Plan. I
have not been reimbursed from any other source including insurance programs or other programs offered by my employer. None of
these expenses have previously been submitted. I understand and agree that since these expenses are to be reimbursed they may not be
claimed as deductions for income tax purposes. Additionally, I am aware that unused funds may be forfeited or otherwise handled in
accordance with the plan document and the current IRS law. I hereby request reimbursement for these claims.
: ________________________________________________ DATE
CLAIM PROCESSING & PROCEDURES
• PAYMENTS: DIRECT DEPOSIT PAYMENTS ARE PROCESSED WEEKLY (WEDNESDAY). PLEASE
ALLOW TWO BUSINESS DAYS FOR FUNDS TO BE IN YOUR ACCOUNT.
CHECKS ARE ISSUED AT LEAST TWICE A MONTH (EVERY OTHER WEDNESDAY).
• CLAIMS MUST BE RECEIVED AT LEAST 2 DAYS PRIOR
TO THE SCHEDULED PAYMENT DAY TO BE
• MEDICAL CLAIMS SUBMITTED REQUIRE COPIES OF BILLS/STATEMENTS/RECEIPTS SHOWING DATE
AND TYPE OF SERVICE. (NO CANCELLED CHECKS/CREDIT CARD RECEIPTS).
• YOU MAY FAX A CLAIM AND YOUR RECEIPTS TO CPA, INC. PLEASE LIMIT TO 10 PAGES.
• ELIGIBLE EXPENSES REQUIRE THE DATE OF SERVICE FALL WITHIN YOUR PLAN YEAR, NOT WHEN
• GROUP EXPENSES TOGETHER ON ONE LINE (See Example Below)
IRS Reimbursable Expenses (examples). Please call CPA, Inc. if any questions.
Mileage traveled to/from a medical facility:
(16.5 cents per mile effective 1/1/2010)
Insulin and Testing Supplies
*IMPORTANT NOTE: Due to new Health Care Reform, Over-The-Counter items are no
longer eligible expenses, effective 1/1/2011.
The following items require a physician prescription each plan year stating the expense is
necessary to treat a particular medical condition/disease. Wellness procedures and programs are NOT
Health Club memberships
Characterization of the recently sequenced Gluconobacter oxydans DSM 2343 in comparison to other G. oxydans wild type strains Christoph Bremus, Cornelia Gätgens, Ute Herrmann, Stephanie Bringer-Meyer and Hermann Sahm Institut für Biotechnologie 1, Forschungszentrum Jülich GmbH, D-52425 Jülich, Germany Introduction G. oxydans is an obligate
Presence of a Na1-stimulated P-type ATPase in the plasmamembrane of the alkaliphilic halotolerant cyanobacteriumAphanothece halophyticaKanjana Wiangnon1, Wuttinun Raksajit1 & Aran Incharoensakdi1,21Department of Biochemistry, Faculty of Science, Chulalongkorn University, Bangkok, Thailand; and 2Center for Environmental Stress Tolerance inPlants, Faculty of Science, Chulalongkorn University