Education Reimbursement Form

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Box 785040 Orlando, FL 32878-5040 Fax: 1-888-211-9900 Education Information Employee Certification (Required) Education Reimbursement Form Yale University (05102) Employee Certification (Continued) By adding my signature on the first page, I certify that the information I’m providing is correct and the expenses for which I’m requesting reimbursement, or for which I’m validating: ƒ Were incurred for services or supplies received by my eligible dependents or me under the plan ƒ Were for services or supplies furnished on or after the date my spending account takes effect ƒ Haven’t been reimbursed in any other way or from any other source and won’t be submitted for future reimbursement and ƒ Don’t include any amounts that are otherwise payable by plans for which my dependents or I are eligible..

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