Submitting your ADP Debit Card Expense Substantiation Form
Review these instructions before submitting!
Go green! Submit online! Visit:
Helpful tips for documentation:
1
FAX
1-866-643-2219
MAIL
ADP Spending Accounts, P.O. Box 34700,
Louisville, KY 40232
 https://myspendingaccount.adp.com
Ensure that the documentation is legible.
 The use of highlighter causes items to not be legible on the documentation;
Highlighter use is not recommended.
 Send only photocopies of your claim form and documentation
keepand
thelast
originals
- Your–first
namefor your records if submitting via US Mail.
Helpful tips to fill out this form:
– All in CAPITAL letters
6 – The date when the card
was used/swiped
2
1
3
2 – Your employer name
7 – The amount for which
1
the card was swiped
4
Check
1
3 – Your complete mailing
8 – Name of the merchant
address and day time
phone number
where the card was swiped
4 – Your Social Security
Number (SSN)
5*
**
1
6
7
8
1
1
1
1
9 – This can be a document
9
1
5* – Check mark the type
of documentation
submitted
ID or any other reference ID
given by ADP
10 – Your signature acknowledging the
certification (in Section 3)
10
*Copy of itemized receipt / EOB
What do we need on the Itemized receipt?
o
o
\ o
o
Date of service or product
Amount of service or product
Description of service or product
Name of the provider and name of the patient
Important: All over the counter medicine/drugs require a copy
of doctor’s prescription or a receipt containing a RX number.
*Alternate receipt: For any reason, if you cannot submit the receipt for this expense, you can check the box “alternate receipt”
on this form and submit any other eligible expense incurred during the same plan year.
*Check: If you do not want to submit any receipt for the expense for which you have swiped your ADP Debit card, you have the
option of sending your “personal check” to ADP for the same amount to approve this transaction.
For Questions Call
Customer Service : 1(888)557-3156
1-888-557-3156
ADP Debit Card
Expense Substantiation (Validation) Form
FAX TO: 1-866-643-2219 TOLL FREE
Use this form only if you received a request to submit receipts for a purchase made with your ADP Debit Card.
HCSUBF
Reset
Go Paperless & avoid filling out this form. Upload your Debit Card Validation receipts online for
fast and secure processing! Visit: https://myspendingaccount.adp.com
This information is privileged and confidential. If you are not the intended recipient, notify the sender immediately and destroy this document and all supporting
attachments. Further use or disclosure is strictly prohibited.
THIS IS NOT A REIMBURSEMENT CLAIM FORM
TIPS TO REMEMBER WHEN SUBMITTING ADP DEBIT CARD EXPENSES FOR VALIDATION:
1. Use Blue/Black ink only. Do NOT highlight Substantiation form/receipts.
2. Do NOT mail original receipts, only copies. Credit Card receipts are NOT acceptable.
3. Most Over The Counter (OTC) items now require a copy of doctor’s prescription or a receipt with Rx number for reimbursement.
SECTION 1: EMPLOYEE INFORMATION
Employee Name
Employer Name
First
Last
Address
City
State
Zip
Phone
Social Security Number (SSN)
(No Dashes)
SECTION 2: YOUR HEALTH CARE DEBIT CARD PURCHASE INFORMATION
Substantiation Document
Date of Card Swipe
Card Swipe
Amount
Check the appropriate box
MMDDYY
Dollars . Cents
Copy of itemized receipt / EOB
Alternate Receipt
$
Check
Copy of itemized receipt / EOB
Alternate Receipt
$
Check
Copy of itemized receipt / EOB
Alternate Receipt
$
Check
Copy of itemized receipt / EOB
Alternate Receipt
Merchant Name
$
Check
Optional: If this is a re-submission, please enter your Reference ID here:
FAX: 1-866-643-2219 (Toll Free)
MAIL: ADP Spending Accounts
P.O. Box 34700
Louisville, KY 40232
CUSTOMER SERVICE: 1-888-557-3156
SECTION 3: CERTIFICATION
I certify that the expenses listed above qualify for reimbursement under the applicable IRS regulations and guidance and have been incurred by me or by my eligible
dependents. The claimed expenses have not been reimbursed nor will I seek reimbursement from any other source. I understand that where an expense is reimbursed
and is subsequently deemed ineligible, I am responsible for reimbursing the plan for any such expense. Additionally, these expenses are not being claimed as tax
deductions under the IRS code. Bills, statements, receipts or other proofs of expenses are attached. I have read and understand the instructions on the above page(s).
Signature
HCSUBF
Date
MMDDYY