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Itemized deduction / Income tax in the United States / Reimbursement / Medicare / Government / Business / FSA debit card / Cafeteria plan / Taxation in the United States / Employment compensation / Flexible spending account


Microsoft Word - FSA Claim Form - Healthcare JMA (FINAL).doc
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Document Date: 2014-09-03 11:54:53

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File Size: 160,16 KB

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City

Mesa / /

Currency

USD / /

/

IndustryTerm

insurance coverage / insurance payment / healthcare / /

Organization

**NAME OF PERSON RECEIVING RELATIONSHIP PROVIDED mm/dd/yy SERVICE / DATE SERVICE / Internal Revenue Service / DESCRIPTION OF SERVICE / FSA / Medicare / /

/

Position

COB / orthodontist for each periodic reimbursement request / orthodontist / /

ProvinceOrState

Oregon / Arizona / /

Technology

cellular telephone / /

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