YFX HEALTH STIPEND reimbursement

In an effort to support full-time staff in out-of-pocket expenses not covered by individual medical, vision, and dental health insurance, Youth FX is making an effort to bridge that gap by providing up to $2,500 Health Stipend.

At this time, health stipends can only be dispersed on a reimbursement basis. This means that staff will have to pay for expenses out-of-pocket and submit this form for a Tax-Free Reimbursement. Please remember to keep track of receipts!

Once the form has been submitted, Youth FX Admin staff will review your form and follow-up via email with additional questions if necessary, and confirmation of whether or not the cost has been approved, and if approved when you will receive your reimbursement.

Please complete the form below

Employee Name

First Name

Last Name

Employee Email

Date of Expense

Please insert the date the expense was made

YYYY

What was the expense?

Please give a brief description of what the expense was.

Why was this expense not covered by your health insurance?

Please highlight why your expense was not covered.

How much did you spend?

Please insert the amount you spent

Please email a clear image of your receipt to info@youthfx.org

Before sending a photo of the receipt, please rename the file following this naming structure “YYYY-MM-DD_Your Full Name_Vendor Name_Health Stipend Reimbursement_Amount” NOTE: for “amount” please add a whole number, no decimals. EX. 2021-08-30_Sam Smith_Albany Med_Health Stipend Reimbursement_1234

Youth FX Inc. is 501c3 non-profit organization supported by our community and the following partners:

YFX Health Stipend Reimbursement Form

YFX HEALTH STIPEND reimbursement

Please complete the form below

Youth FX