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[{"$nulls":24},"PO Box 423\nNobleford, AB T0L 1S0\n(587) 352-9935\ninfo@smartinbenefits.com"]
[]
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[null,"Smartin Benefits Plan Claim Form"]
[]
[null,"A: Employee Information (Plan Member)"]
[null,null,"Plan Member Number (99-9999-999)",{"$nulls":16},"Today's Date (YYYY-MM-DD)"]
[{"$nulls":4},"-",{"$nulls":4},"-",{"$nulls":9},{"$f":"TODAY()","v":"2021-11-08"}]
[]
[null,null,"Company Name (Plan Owner)",{"$nulls":16},"First and Last Names (Plan Member)"]
[]
[]
[null,null,"Please Select your Province (for Tax Calculation)",{"$nulls":16},"Note: If your email, mailing address or any other information changed, please notify our office immediately."]
[null,null,"Alberta",{"$nulls":14},"< click inside frame"]
[]
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[null,"B: Claim Details",{"$nulls":52},"GST/HST"]
[null,"#","Expense Date",{"$nulls":3},"Patient Name",{"$nulls":9},"Claim Description",{"$nulls":15},"Amount",{"$nulls":20},"Alberta",0.05]
[null,1,{"$nulls":51},"British Columbia",0.05]
[null,2,{"$nulls":51},"Manitoba",0.05]
[null,3,{"$nulls":51},"New Brunswick",0.15]
[null,4,{"$nulls":51},"Newfoundland and Labrador",0.15]
[null,5,{"$nulls":51},"Northwest Territories",0.05]
[null,6,{"$nulls":51},"Nova Scotia",0.15]
[null,7,{"$nulls":51},"Nunavut",0.05]
[null,8,{"$nulls":51},"Ontario",0.13]
[null,9,{"$nulls":51},"Prince Edward Island",0.15]
[null,10,{"$nulls":51},"Quebec",0.05]
[null,11,{"$nulls":51},"Saskatchewan",0.05]
[null,12,{"$nulls":51},"Yukon",0.05]
[null,null,"Note: Please use a new form if more lines are required.",{"$nulls":27},"Total Claim Amount : A",null,{"$f":"ROUND(SUM(AG22:AJ33),2)","v":0}]
[null,{"$f":"IF(AG34>=7000,4%,5%)","v":{"v":0.05,"d":"5%"}},"By signing below, you certify that all health services have been purchased for an eligible member of household.",{"$nulls":27},{"$f":"CONCATENATE(\"Administration Fee (A x \", TEXT(AdminFee,\"0%\"),\" ) : B\")","v":"Administration Fee (A x 5% ) : B"},null,{"$f":"IF(AG34<>0,IF(AG34<100,10,ROUND(AG34*AdminFee,2)),0)","v":0}]
[null,{"$f":"VLOOKUP(C17,TaxLookup,2)","v":{"v":0.05,"d":"5%"}},{"$nulls":28},{"$f":"CONCATENATE(\"GST/HST on Administration Fee (B x \",TEXT(GST,\"0%\"),\" ) : C\")","v":"GST/HST on Administration Fee (B x 5% ) : C"},null,{"$f":"ROUND(AG35*GST,2)","v":0}]
[null,null,"Signature:",{"$nulls":27},"Total Payment Amount (A + B + C ) : D",null,{"$f":"SUM(AG34:AJ36)","v":0}]
[]
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[null,"C: Next Steps"]
[null,"  Important: Please number each receipt with the corresponding line number as on the claim form."]
[null,"  Please include the following documents when submitting your claim:"]
[null,"  1. This completed claim form",{"$nulls":13},"Email to: info@smartinbenefits.com"]
[null,"  2. Clear copies of all receipts ",{"$nulls":13},"Queries: (587) 352-9935"]
[null,"  Note: Please keep your original receipts."]