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Personal Use Statement Online  Form

Personal Use Statement Online Form

Use a personal use statement template to make your document workflow more streamlined.

The Health Care Spending Account HCSAccount you agreed to the following I will only use my HCSAccount to pay for IRS-qualified expenses permitted under the State of New York s plan incurred by me my spouse and my IRS-eligible dependents I will exhaust all other sources of reimbursement including those provided under my employer s plan s before seeking reimbursement from my HCSAccount I will not seek reimbursement through any additional source and I will collect and maintain sufficient...
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