HSA Reimbursement Form

Instructions:

Fill out completely with a description of reimbursement. Missing info will delay payment.
Attach one file with copies of all receipts, preferably a PDF.
Specify if the check should be mailed to the vendor or made available for pick-up.
REMEMBER – HSA DOES NOT PAY SALES TAX on items purchased for its use; therefore sales tax will not be reimbursed
A receipt of your submitted request will be emailed to you (keep for your records).

Check Payable To:

Total Amount For Reimbursement:

Should check be picked up or mailed?

If check is to be mailed, provide the address.

Expense 1 - Amount

Place of Purchase

Committee/Event:

Expense Is For:

Expense 2 - Amount

Place of Purchase

Committee/Event:

Expense Is For:

Expense 3 - Amount

Place of Purchase

Committee/Event:

Expense Is For:

Attach Receipts

Please attach one file with copies of all receipts

Questions?

Please contact Caroline Ferrucci at Ferrucci.Caroline@gmail.com or Chris Clemente at clementeac@optonline.net