ONSTOR
CLAIM FOR REIMBURSEMENT
								
Employee 								 SSN #	  XXX   -  XX          -     		               
	
DEPENDENT CARE EXPENSE CLAIMS

NAME OF
DEPENDENT	PERIOD COVERED	SSN, NAME, & ADDRESS OF PROVIDER OF SERVICE	AMOUNT INCURRED	
	FROM 	TO			

					

					

           TOTAL DEPENDENT CARE EXPENSES:	$	
*NOTE:  The total amount claimed under the plan for any coverage period must not exceed the lesser of your earned income for the plan year or the earned income of your spouse.  (If your spouse is either a full-time student or is incapable of taking care of himself or herself then he or she is deemed to have monthly earnings of $200 if there is one child or dependent and $400 if there are two or more.)  No payment may be made under the plan if the service provider is your dependent for federal income tax purposes or is your child or the stepchild and is under age 19.

UNREIMBURSED MEDICAL EXPENSE CLAIMS

DATE EXPENSE INCURRED	NAME OF PROVIDER OF SERVICE	EXPENSE DESCRIPTION	PERSON FOR WHOM EXPENSE WAS INCURRED	NET AMOUNT	

					
					
          TOTAL UNREIMBURSED MEDICAL EXPENSES:	$	
READ CAREFULLY
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 the Company's Cafeteria Plan with respect to such expenses.  The undersigned fully understand 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 penalties and taxes including federal, state or city income tax on amounts paid from the plan which relate to such expenses.

Employee Signature                                        				 Date					               
					
Sherryl A. Cobb
Nicholas & Company
1487 Oakdale Lane, Redding, CA  96002
(530)223-1866     fax (530)223-4156
email:  sherryl@nicholasandhicks.com
						
CLAIM FILING INSTRUCTIONS

Who can file a claim form?
•	  Only employees participating in the Cafeteria Plan can file a reimbursement claim form.
•	  Employees can file a claim during the current plan year and prior to the 90th day after the plan year end.

What expenses can be claimed?
•	  Only expenses incurred during the Plan year can be claimed for reimbursement.  Each year is treated separately and the year of the claim is the year the expense was actually incurred by the participant.
•	  Allowable expenses are the same as those allowed for tax purposes.  A summary list is provided here for your convenience.
              	Qualifying Dependent Care Expenses
Expenses necessary for you to be gainfully employed.
Expenses paid to a dependent care center.
Expenses paid for care of a dependent under age 13.
Expenses paid for care of a dependent who is physically or mentally incapable of caring for his or her self.
Expenses do not qualify if they are paid to your child under the age of 19.
•	  YOUR CLAIM CAN BE DENIED IF IT DOES NOT INCLUDE THE PROVIDER'S ID NUMBER.
				Qualifying Unreimbursed Medical Expenses
Only medical expenses not reimbursed by insurance can be claimed.
	Acupuncture			Hospital bill
	Alcoholism Treatment			Hypnosis for treatment of an illness
	Ambulance hire			Insulin
	Artificial limbs			Laboratory fees
	Artificial teeth			Nurses' fees
	Birth control pills        			Obstetrical expenses
	Braces			Operations
	Braille - books and magazines			Orthopedic shoes
	Car controls for the disabled			Oxygen
	Chiropractors			Physician fees
		Christian Science practitioners' fees				Prescription  and over the counter drugs
	Co-insurance amounts you pay			Psychiatric care
	Contact lenses			Psychologist fees
	Cosmetic Surgery (for medical purposes)			Seeing eye dog and its upkeep
	Crutches			Sterilization fees
	Dental fees			Surgical fees
	Dentures 			Therapy treatments
	Diagnostic fees			Vitamins by prescription
	Eyeglasses			Weight loss program if prescribed by a doctor
	Hair transplants			Wheel chair
	Hearing devices and batteries			X - rays

Completion of the claim form
•	Complete all information of the claim form for each amount claimed for reimbursement.
•	Make sure the claim does not include items for more than one plan year.  Use different claim forms for different years.
•	You must sign and date the claim form.
•	Copies of receipts must be attached to this claim form in order to be reimbursed.  You can seal them in an envelope if you are concerned with privacy.  Please keep the original receipt for your records.

Nicholas & Company, Inc.
1487 Oakdale Lane, Redding, CA  96002
(530)223-1866  fax (530)223-4156
email: sherryl@nicholasandhicks.com