Are you looking for a convenient and affordable way to travel? An answer may be closer than you think. Introducing Prime Flex Transportation - the flexible mobility solution that can take you where you need to go. With its easy-to-use form and broad coverage, it promises an efficient, seamless ride every time. Keep reading to hear more about how this transportation option has companies and customers alike buzzing with excitement!
| Question | Answer |
|---|---|
| Form Name | Prime Flex Transportation Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | paper models downloadable printable, printable air transportation, transportation word, need to type up printable paer |
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PrimeFlex
Form # 6 – Mass Transit and Parking Expenses Reimbursement Claim Form
PLEASE COMPLETE THIS FORM AND FAX IT – ALONG WITH COPIES OF YOUR RECEIPTS – TO PRIMEFLEX AT
To be completed by employee
Employee Information (Please print clearly)
PLEASE CHECK HERE IF THIS IS AN ADDRESS CHANGE
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Eligible Mass Transit and Parking Expenses To Be Reimbursed
Please only list
2009 monthly limits are: $230 ($120 max.:
Description of Expense
Date Incurred
Amount of Claim
Total amount this claim $
READ CAREFULLY!
The undersigned participant in the plan certifies that he or she actually incurred all expenses for which reimbursement or payment is claimed. By submission of this form, the participant certifies that all expenses were incurred while the undersigned was covered under the Plan. The undersigned participant certifies that amounts claimed are not eligible for payment or reimbursement under any other plan or program. If applicable, the undersigned participant certifies that he or she has purchased the transit pass and has already used it or will personally use it during the month. The undersigned fully understands that he or she alone is fully responsible for the sufficiency, accuracy and validity of all information relating to this claim which is provided by the undersigned. The undersigned further understands that no transit and/or parking tax credit is permitted for amounts for which reimbursement is made.
Employee Signature: __________________________________________________ Date: ______/______/______
Retain the original receipts and a copy of this form for your records. For Tax Purposes – Use only for expenses incurred in the same plan period for employee only.
Mail this form to: PrimeFlex Claims |
PrimeFlex Customer Service: |
1487 Dunwoody Drive |
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West Chester, PA 19380 |
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