ࡱ>  5%bjbj ܳhhs IIMMMaaaa}ax$!!!!!|||$$$$$$$p%(f$Me!l|e!e!$II!!2$!!!e!.I!M!$!e!$!!rw#TJ#!0Y1 a!X#$H$0x$#x(!x(#x(M# |^!^L|||$$! |||x$e!e!e!e!x(||||||||| :  CLAIM FORM Please read requirements on reverse side ________________________________ ________________________ ________________ Last Name, First Name, MI (Please Print) Employer Social Security Number or employee id (EID) as appropriate __________________________________________________ __________________________________________________ Street Address City, State, Zip Dependent Care Assistance (day care, babysitting, etc.) Dependent care expenses must be for a dependent who is incapable of self care or under the age of 13 at the time the care was provided. Name of Dependent ageDates Care ProvidedName, Address, and Taxpayer Identification Number of Care ProviderCost for Care Period ASI use onlyFromTo* Total Dependent Care Amount Requested I provided the dependent care as stated above. __________________________________________ __________ _________________ Care Provider's original signature Date SSAN/Tax ID# Unreimbursed Medical Benefits Date Medical Care Provided* Name of Medical ProviderGeneral Medical Expense Description. Include medical condition for over-the-counter items.Patient Name Relation-shipAmount that is your responsibility ASI use only Total Medical Amount Requested  Please arrange documentation in order listed above. *Claims for future services will not be accepted. The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while the undersigned was covered under his/her employer's Flexible Spending Plan with respect to such expenses and that the expenses have not been reimbursed and reimbursement will not be sought from any other source. Any Dependent Care Assistance expenses claimed here were provided for my dependent under the age of 13 or for a dependent who is incapable of self care. The undersigned fully understands that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes including federal, state, or local income tax on amounts paid from the Plan which relate to such expense. _______________________________________________________________________ _________________________________ Employee's Signature Date ASI Mail or FAX to ASI ALONG WITH P. O. BOX 6044 SUPPORTING DOCUMENTATION COLUMBIA MO 65205-6044 E-mail: asi@asiflex.com FAX (573) 874-0425 Internet http://www.asiflex.com  Claim forms: You may copy this form, obtain forms on the Internet at http://www.asiflex.com, or request them from your personnel/payroll office, or call ASI at 1-800-659-3035 (442-3035 calling from Columbia, MO). Claims payment and account information available 24 hours a day 7 days a week: - Complete history including available funds on the Web at www.asiflex.com (Account Detail). You will need your P.I.N., which you can find on your enrollment confirmation. Orthodontics: Requests may be reimbursed for a reasonable monthly payment on or after the payment is due and paid. The payment must be a reasonable approximation of the value of each month's service. You may only file claims for orthodontic payments while treatment is in process. You must submit a paid receipt from your orthodontist or a photocopy of the monthly coupon and your check. Pre-payments are not allowed. You must submit a written statement from the orthodontist showing the charge for the initial installation work, when it was completed and a paid receipt to claim an initial down payment or appliance fee. Medical equipment: Requires a letter from a physician every 12 months stating the nature of your medical condition, the specific equipment needed and that the equipment is essential to the treatment. Claim Filing Requirements Print your name, address, social security number or employee id (EID) as appropriate and your employer's name. List expenses by date & arrange the supporting statements in the same order. Highlight or circle the service dates on your documentation. If you have several statements from the same provider, you may subtotal them and list them on one line with a range of dates. Day care claims - complete the Dependent Care Assistance section Health care claims - complete the Unreimbursed Medical Benefits section (The amount column should be the amount you are requesting after any insurance payment or provider discount for each expense). Enclose required documentation*. A written statement from the dependent care or medical (Dr., hospital, pharmacy, etc.) provider of the service or an insurance company benefits statement showing all of the following: The name of the dependent care or medical service provider, The date or range of dates of medical service or day care. Although this date may be the same as the date paid it must be clear on what date the service was provided. The services must have already been provided. A description of the service provided (for example, for health care, "dental cleaning", or for day care "day care"), The name of the person or persons receiving the medical or dependent care, and The cost of the service, not just the amount paid. *Dependent Care claims only. - You may either provide documentation from the day care provider or have the provider complete the Dependent Care Assistance Section, then sign on the "Provider's Signature" line and date the signature. You do not need to do both. Requests filed without the above documentation cannot be processed and will be returned. Sign the claim form. Keep copies for your tax records. Mail to the address on the front of this form or Fax to (573) 874-0425. This is not a toll-free number. Employee use of an office fax machine may not be appropriate. Please check with your employer before using an office fax machine. Over-the-counter medicines & drugs: Additional filing requirements for plans allowing these under the medical FSA: The receipt or documentation from the store must include the name of the drug printed on the receipt. This information must be provided by the store, not just listed by the participant on the receipt or on the claim form. The participant must indicate the existing or imminent medical condition on the receipt, on the claim form, or on a separate enclosed statement each time these items are claimed. Purchases for general good health will not be accepted. To claim vitamins, herbs or nutritional supplements, you must have a written diagnosis of the medical condition and prescription of all specific items for that condition on file with the claims office. You must renew this physician notice every 12 months and file it with the claims office with the first claim submitted for those items each plan year. ()4BQRS! # 9 q  567>FVZ[žŷַŮŘёъŊёzjhCJUmHnHu h5CJ h5>*jh5UmHnHu hCJH*h5CJH* h5CJ h;CJ hCJ hCJ h5h hCJ hCJ hCJ$ hCJ(jhUmHnHu0)RS 9 9 q  % h } ~ $$Ifa$$If$ @a$ vZ-0 n( L, 0vZ-x^x$a$ =77.. $$Ifa$$Ifkd$$IfTl4ֈ#a*`b 04 laf4T $kd+$$IfTl4֞1 #a*     04 laf4T$If $If kdf$$IfTl4ִ1 #%a*```` ``(`0    4 laf4T $If kd$$IfTl4ִ1 #%a*      ( 0    4 laf4T $If kd$$IfTl4ִ1 #%a*```` ``(`0    4 laf4T $If kd;$$IfTl4ִ1 #%a*      ( 0    4 laf4T $If kd$$IfTl4ִ1 #%a*```` ``(`0    4 laf4T $If kd$$IfTl4ִ1 #%a*      ( 0    4 laf4T $If kd $$IfTl4ִ1 #%a*```` ``(`0    4 laf4T $If kdW $$IfTl4ִ1 #%a*      ( 0    4 laf4T    OAA-DM ^kd $$IfTl4\#a* 04 laf4T x$If$If  , p ~ $$If^a$$If $$Ifa$$a$ -DM  "&;-DM ^ .((($Ifkd $$Ifl4֞vWt"'Z-m@ F04 laf4 $If $Ifkd$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4 $If $Ifkd$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4 $If $Ifkd$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4 $If $Ifkd,$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4 $If $IfkdQ$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4 $If $Ifkdv$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4 $If $Ifkd$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4$If $Ifkd$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4     $If$Ifkd$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4$If$Ifkd $$Ifl4ִvWt"'|)Z-m@ F0    4 laf4 !"$If"#$$Ifkd/$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4$%&'()*+$If+,-$IfkdT$$Ifl4ִvWt"'|)Z-m@ F0    4 laf4-./01234$If457$Ifkdy$$Ifl4ִvWt"'|)Z-m@ F0    4 laf47WXYZRHHH -DM kd$$Ifl4^\vWt"'Z-F04 laf4$If v@Bd$If[234567jklrsGIǘ|ttke^ h6CJ hCJh56CJhB*ph#jhB*UmHnHphuhB*CJph h56 h5CJhCJmHnHujhCJUmHnHu hCJh h5 hH* h5CJ hCJ h5CJ!jh5CJUmHnHu hCJ$45567mmm -DM ^-DM ^ $v-DM ^v vv-DM ]v^vv-DM ]v$vv-DM ]v^va$$ v-DM ^va$ v-DM ^v 7ksHIEFG["#9 & F 8 & F 8 & F$a$^ 8 0*@-DM ^EGT\#ABE '/5gis? E j o !!!!!4%5%hB*CJph hCJ h5 hH* h>*h56H*h56; h5CJ h56h hCJ2  i j  !!""#2%3%4%5% & F & F 8 8 88^8 & F 8(/ =!"#$% nV8o:]=PNG  IHDRdX9PLTEֽνΥֵ޵ƵsƄք{֔sƌ֌΄BkJs{B{J1cZ!kc9k9s1k)c!RZ1cBJsBk)c1k{)Z1k9s1k{Rs!RRR1{{sJs)RR9c{Bk9sB1{9kcB1Zs!B)R91ޔΜ9Z1!sBZ1{!{΄s991c){{k!֌Zk)1cs1BBR!9))9!{RZZc!ZcJRJR9Bcs19)1便νﵵ筭ޥޜޜ猌{{ss{{Ƅ֌{{΄kksskkssZZZZkkRRBB))))!!!1BJRck{JBJB)!֌{skccZB9k甌ΜcZ9)9)ƽZJ)scJ1ƽﵥkZB))ƵkJsƵュƵubKGDHGIDATx; tUՕb*^ O Bta QE @@ * ƈ"\D%@HPZBR={ F:0`qDܗj]kVZys禥jPsS榦ܦ .;wo5}o?ζm:qqۉ555;XU}ڎ];ٵ;{={wط=uo uϬ[M8qׯϮ+/ohh(Wιw*CamiO+r]y,\žJRs).\) F<-B]TUJ h$g)Jso啕`Qu7hKI%# 614c6s@HFaSv!> h=α}zh1q{~x_ETmNJ M02PD\!" Cc $G˪e늧4p}y b7*an dqU!v#t͖ ^(Csј',| Hd2mHPFlE'?xg.z~TEږ'6⿭[OG8u+l[1BC 6Ue/ 't ÿutͫo^-pS-gfՇ`῅~@#5 ,+b 1{Ka"Tt^tXqY̸2ƙ hVd_H Mlq |_\jSg[[8]RzVߘ  7Uiƃk*獼!7:aĠanھ=>=':hР>Yك߿oϾ׃ӫGVֵ={^UտO{洶y99?;uҥS޽ z6<USjO㱽ׇ;D'`puLOرcӿվ}_F]{iO m\jniBNRзqD^C:^'pdQ-x4T!2inN xǒ-zBeojiZQFup@`3pk/((߼(G>wܺsIAt*jzp[u6W>,-m5 6+J"j)Үhچoփ5՛=Zg3^׃'=v؞{(QTzy{G :oLK X#c6j1ghf#IZS(K&NH6Q"ADF;а^䳟 ߏ8R܁ɾ#&w ÷tc_7) c_2w2nRyoUDq=!?9؎Sk-q(;# egt((*48*c.XmDMmd&Y3vCvqrE.I"+AM`IX54+2Dt}ixz ڼJX;|b;S΁$VǤQÙI)z\|9/6Wc(pZC%Ǭd RaTd icX>f"nEg LvCnH2KZE4]LWSR0NTt1P3ŝoŹ 1X <Ҧ ^V}"*b{$Y|m6n.(Eq1oeݔ=7_E0\2X:D[ ?H*hilarpZ&u)˟ x'Plx|*-a@$"2i2K-;}tQ+!WTP..S Oё8Or* 6q9%k!B. sd*%Er,߰ ^s^T7YRGl>ujJ,`@'Ȍ,I'\gp p}_9hBi,e+uVmzYdV2i#ցe*I-q%p’N` IH.Cl]xX1jU |N!Hm1CHӹ!+#x")_w*r]Ҙ}S'r+,G`T ' z_Fg|MeraKS pƆqI 6BRqWh (!K?$Aiyk#ea:MyY`~-(jmѬ ev\AD؆~_$)26-f̷eQ:E(HN+a"6;Y╭,V5+pBT~Z))yZJMǂY-Pqӑ >#x񐠃BB3։+U \0,?UN܋rl{/ߏ>A>"&{ E<8kS9Z~Bۉ0qY!)1y$Y\x;6 (|uJ_k 2<՚ȭP) Gcm7M_gQ" "2^#t&B}eػi-6@EWjΏp2ᝦPn8ay@b{gS6Β٠`b8uOGa|7gzTXj8-#/%|4(N)@9XNS+Xձ3TxZnX#rZ,Fs4u!4|y2=Vye5{$گXzLf`17SVygco1# x\QE.`T2:H^8^Kn!§n7|XR i6&9Sl"5oC,uxO^Yj[mI2[Os7 "D0i2;E+65дQ 2.3踶^^Ҙd|-R(SźMZU^5*v?40gG~^o?zy0V_}͍| 9Àg~ϵ3C>k3.7lL?3)d31pu˵T9r {()"ͷ-kdK6x8t|_B\pLe[iwbAc"4a9z^g,v4s6yNxD ?x{ 8S0DXʛ9kĒg(JMp WYe̜\>.sʌ%Ƞ1)ɳԱЗ&ո3ĉұzҎ9Np豹ֈǽ<ߍG9zk{t=es)jN#h\oSnґeo:b50{sZ4gfG|SFFǎ/νiv\_hSgRK&m S \3² e"Z\ Iї`[%[;vdFKݿd}i|[C"t^SmjC{wݛ{'>j=|ꔯjOA(!&姾U$[_~t@Aq/xUNy^(`Va'Kn]WbּKʽCfϜ7uIrΒ)|]z1C4TÖ8ӲV?8Mk*Kz۷Ae@HZgOqPWyCI}+Ҩ-…2~g.Essd ]7Zl>FLDx]@MLRZ֋aEN R~U__*U*?R+@o!Cc :c1<,\Hw&;a(;u1Gȟ @WJVDL"ybp'/sBoNO|p&y۶رCh~kkOVTx6A vMMYp:TpC 6b~݋ xĕ#Kʄs>tZIT[y87a$`%'&s)>`ʄ} U `?irugG脉 "WE1Tʵi'*̘pu`rP~nR: )7]+9E}&ސݩٟͧgfd>5x07{vnܬ%ML.?MOr0(|*Gtz&c&tu8sifzS׮Lڍ_]kGE> CJFm(xB,H0l ݰF7;>]gwoOOWwdMS sd5aM3ˈM1k&qM߆cL[;|p }YkД"T'Z|-dd2^0ie Th 2Ɇs@L8}F8 Ud`;ଌ);FKP 'X$2 )\jG`8uz1NKc2 OxsKR@5)ie ʤ9г 㤈}"$۠FoM SVw%Z6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8 Normal_HmH sH tH >@>  Heading 1$$@&a$CJ$<@<  Heading 2 $-D@&CJ <<  Heading 3 $-D@&5PP  Heading 4$ 0*@-D@&^CJDA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 0U0 Hyperlink>*B*TC@T Body Text Indent 8^B*CJPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] I 5765849I 5 [5%EH  "$+-4775% !"#$%&'()*+,-./0123456789:;<=>?@ABCDFGIl:;,b$V8o:]=*@r :(  \B @ C D#" ?bB  S D#" ?bB @ S D#" ?bB ) S D#" ?bB / S D#" ?t 2 S 0A?ASI Logo#" ?\ 4 # 4#" ?  \ 5 # 5#" ? \ 6 # 6#" ?  \ 7 # 7#" ?  \ 8 # 8#" ? \ 9 # 9#" ? B S  ?5Z l m n o p q 52@O<t) t/0!t8TT@EET9m0!Q-)t5m0*Q-*urn:schemas-microsoft-com:office:smarttags PostalCode8*urn:schemas-microsoft-com:office:smarttagsCity:*urn:schemas-microsoft-com:office:smarttagsStreet9*urn:schemas-microsoft-com:office:smarttagsState; *urn:schemas-microsoft-com:office:smarttagsaddress9*urn:schemas-microsoft-com:office:smarttagsplace < s 4 8 }36 9p6 9 s I 63333336ho5>J-zWsx ^`OJQJo(^`CJOJQJo( h^`OJQJo( 0^`056o(.o5Ws>Jy|s u @5P@UnknownG* Times New Roman5Symbol3. * ArialACambria Math"qhȆȆƲh  24dm m 2QHP(?2!xx Claim Form John RiddickCSC USER    Oh+'0  0 < H T`hpx Claim FormJohn Riddick Normal.dotm CSC USER2Microsoft Office Word@F#@B0I@6R1 @6R1  ՜.+,D՜.+,8 hp|  ASIm   Claim Form Title@@ 4_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnceՊB.ASI reimbursement formmboden1000@mindspring.com Mike Boden  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXY[\]^_`abcdefghiklmnopqrstuvwxyz{|}~Root Entry FY1 Data Z1Tablej(WordDocumentܳSummaryInformation(DocumentSummaryInformation8CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q