DEPENDENT CARE REIMBURSEMENT REQUEST FORM

Please read before you submit your Dependent Care Claim(s)

Important Information regarding the Submission of Dependent Care Claims using this electronic form

Electronic Form Requirements

If you are submitting a claim(s) for Dependent Care Services received from a Provider that has itemized the charges on a bill/invoice, with the provider’s official letter head, you are eligible use this electronic claim form.

You must complete all the required fields on the form.

Claims Not Eligible to use this electronic form

If you are submitting a claim(s) for Dependent Care Services from a provider such as a family member, friend ECT, you must:

  • Print this Dependent Care Form Dependent Care Form
  • Complete all the required fields
  • The Dependent Care Provider must supply their SS# and sign the form. (IRS guideline)
  • You can then scan the form to submit along with your expenses.

Failure to secure the appropriate SSN #’s and Signature on this form will result in a delay of processing your claim(s).

I understand the requirements of using the Electronic form. I accept