Daycare Expense Reimbursement Form printable pdf download

Daycare Expense Reimbursement Form

DAYCARE EXPENSE REIMBURSEMENT FORM

To ensure timeliness of reimbursement processing, please complete form in its entirety, sign and date, and

attach an itemized statement.

PLEASE CHECK ONE OF THE FOLLOWING:

Documentation attached accompanies this manual claim form.



Documentation attached is for a claim submitted online via



Documentation attached is for purchases made with my Benefits Card.



Employee Information

Employee

Social Security Number

Name

Company Name

Employee Email address

Employee Phone Number

Name and Address of

Tax ID or SS#

Dependent Name(s)

Relationship

Date of Birth

Dates of daycare

Provider/Facility

Total amount of reimbursement requested $_________________

If a receipt signed by your daycare provider is not attached, please have your daycare provider sign below:

Daycare Provider Signature

Date

I request reimbursement for the attached expenses under my employer’s flexible benefits plan. I certify that the

dependent care expenses were incurred to allow myself (and my spouse) to be employed outside the home

during this plan year. I understand that the dependent care expenses reimbursed from the Dependent Care

Account cannot be claimed as a Child Care Tax Credit on my Federal Income Tax Return.

Employee Signature

Date

New

Change of address?  No  Yes

Address:

CDS Administrative Services, LLC

PO Box 570

Willmar, MN 56201

Phone: (888) 388-1040

Fax: (320) 235-0988

Email:

Daycare Expense Reimbursement Form