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Employee Name Company Name Ogden City Corporation Yes No Social Security Number _ _ - - . - - . - - . - - . - - . - - . - - . . - - . - - . - - . . Employee Signature NBS - 402(01/04) National Benefit Services, Inc. Toll Free Fax: (800) 478-1528 Salt Lake City Area Fax: (801) 355-0928 Get Your Money Back Fast. Fax Beats Mail! Employee Signature I, the undersigned, attest that to the best of my knowledge these statements are complete and true. I certify these expenses are for valid services provided on the dates indicated and will not be reimbursed or claimed under any other Plan, claimed as a Tax Deduction or Tax Credit. I authorize the release of any medical information to my spouse Date X Total Day Care Expense Age Amount Mo Day Yr Tax ID # or SS# Day Care Expenses Date of Service Service Provider Child's Name Total Health Care Expense Person Receiving Service Amount Mo Day Yr Minimum Reimbursement = $25 Health Care Expenses Date of Service Office Visit RX Dental Vision over the counter drugs Other Services: Please Specify For Quick Claim Processing: For Account Balance: Complete & Sign this Claim Form www.cafeteriaplan.com Attach a copy of supporting receipts, vouchers, bills, etc. (801) 363-3347 All receipts must detail each of the items summarized below 1-888-FLEX125 Please print when using this form OGDEN CITY CORPORATION Cafeteria Plan Claim Form Personal Information Home Address Address Change