iCHRA Reimbursement Tracker

STEP 1

Employee & Plan Information

Employer Group

Employee Name

Plan Year

HRA Type

Monthly iCHRA Contribution ($)

Prior Carryover Balance ($) optional

Annual Contribution
$0.00

Reimbursed

$0.00

Submitted (In Process)

$0.00

Pending

$0.00

True Remaining Balance

$0.00

STEP 2

Date	Vendor / Provider	Description	Amount ($)	Eligible	Category	Status	Receipt	Notes

STEP 3

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