Adoption Reimbursement Request Form

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					                                         Adoption Assistance Claim Form
Employee Information:


  Employee Name __________________________________________________

  Home Address ____________________________________________________________________________________________
Eligible Adoption Expenses:
 City __________________________________________________ State __________________ Zip Code ___________________

  Home Telephone No. __________________________________ Work Telephone No. __________________________________



Employee Adoption Expenses:

        Date Paid             Amount                                 Description
  ____________________ ____________________ _____________________________________________________________

  ____________________ ____________________ _____________________________________________________________

  ____________________ ____________________ _____________________________________________________________

  ____________________ ____________________ _____________________________________________________________

  ____________________ ____________________ _____________________________________________________________

  ____________________ ____________________ _____________________________________________________________

  Total Reimbursement:       ____________________

  Note: Please attach itemized receipts in U.S. dollars for all expenses listed above, as well as a copy of the adoption placement
  decree.




Employee Request for Reimbursement:

  I am applying for reimbursement of adoption expenses listed above, confirming that ____________________________________,
                                                                                                      (Child’s name)
  whose birth date is ____________________, was placed in my home for the purpose of adoption on _______________________.
                                                                                                                       (Date)
  The date for adoption finalization is ______________________.

  I certify that this is a claim for allowable expenses under the ____________________________ adoption reimbursement
  program.
                                                                        (Employer’s Name)

  _________________________________________________________________                          ________________________________
                             (Signature of employee)                                                            (Date)


Form – RUHR6031L – January 2007

Return to Human Resources/Benefits, ADM 111.
                               ADOPTION ASISTANCE GUIDELINES
An Adoption Assistance Allowance will be provided to employees who meet the following eligibility
requirements:

      Employed for 12 consecutive months in a regular full-time status
      Adopting children under the age of 18 who are not related to either parent

If both spouses are employed by Regent University, either spouse, but not both, may apply for an Adoption
Assistance Allowance.

Eligible adoption-related expenses are reimbursed up to a maximum of $3,000.

Reimbursable expenses directly related to an adoption include but are not limited to:

      Agency and placement fees
      Legal fees and court costs
      Medical expenses of the birthmother not covered by insurance
      Medical expenses of the child not covered by insurance
      Temporary foster care costs
      Immigration, immunization and translation fees
      Transportation and lodging related costs

Expenses related to an adoption that are not reimbursable include, but are not limited to:

      Surrogate parenting arrangements
      Adoption of children 18 and older
      Adoption of a spouse's child
      Those paid with funds received from any federal, state or local program
      Those incurred in violation of state or federal law


                                               PROCEDURES
A. To obtain reimbursement, an eligible employee must submit an Adoption Assistance Claim Form to the
   Regent University Human Resources Benefits Manager upon placement of the adopted child. Itemized
   receipts of expenses must be attached to the claim form for documentation.

B. An employee may be eligible for up to 12 weeks of unpaid job protected leave under the Family and Medical
   Leave Act (see Family and Medical Leave Policy). The eligible employee should notify his/her manager of
   the need for time off with as much advance notice as the adoption proceeding allows.

C. In order to add an adopted child to the employee’s medical and dental policies, Change in Enrollment forms
   and a copy of the Adoption Agreement must be submitted within 30 days of placement of the child.

D. An employee must complete an additional 24 months of continuous service in order to be eligible for
   assistance for a subsequent adoption.