DEPENDENT CARE Reimbursement Account Claim Form by apz13064


									                                                                                                                                                                           Print Form

Reimbursement Account Claim Form
                                                          Employee Name ____________________________________________ Employee U ID No.__________________

                                                                          Last               First            MI
                                                          Department _____________________________________________ E-Mail _____________________________

                                                          Work Phone No. (______)_________________________ Home Phone No. (_______)_____________________

                                                          Please list below the name, birth date and relationship of all dependents for whom expenses listed on this
    Dependent Information

                                                          form were incurred. NOTE: Your dependents are those individuals defined as your dependent by the IRS for
                                                          income tax reporting purposes.
                                                          Dependent’s Name                                                Date of Birth     Relationship to Employee

                                                          1. _______________________________________________               _______________       _____________________
    Spouse and

                                                          2. _______________________________________________               _______________       _____________________

                                                          3. _______________________________________________               _______________       _____________________

                                                          Please list all out-of-pocket dependent care expenses for which you are requesting reimbursement.
                                                          The second line is to be used for provider information and may be omitted if previously submitted.
                                                          Name of Provider                           Description of Service Expense            Date(s) Incurred       Amount
    All Submitted Out of Pocket Dependent Care Expenses

                                                          Provider’s Tax ID (required by law)                                     Address             Postal Code

                                                          1. ___________________________             _____________________________             ______________        $___________

                                                            ____________________             ___________________________________               ___________

                                                          2. ___________________________             _____________________________             ______________        $___________

                                                            ____________________             ___________________________________               ___________

                                                          3. ___________________________             _____________________________             ______________        $___________

                                                            ____________________             ___________________________________               ___________

                                                          4. ___________________________             _____________________________             ______________        $___________

                                                            ____________________             ___________________________________               ___________

                                                                                                                                    TOTAL EXPENSES:                 $___________

                                                          Attach original receipts or statements with this form, listing the service provider(s), the service(s) provided, for
                                                          whom, the amount charged as well as the service date(s). Canceled checks and credit care receipts are NOT
                                                          acceptable. Neglecting to submit required records may delay reimbursement. Claim forms must be received
                                                          by Human Resources no later than the 10th of each month for a reimbursement to be included in your
                                                          month end paycheck.
                                                          Please retain a copy of all submitted forms and documentation for your records.

                                                          I hereby certify that the expenses listed above have been incurred by me within the calendar year in which I seek
                                                          reimbursement and that these expenses qualify for reimbursement from my account. I agree that I will not receive

                                                          reimbursement for these expenses from any other source or declare such expenses as a deduction on my Federal

                                                          income tax return.

                                                          Employee Signature _____________________________________________ Date ______________________

Please return claim forms to: Human Resources, Benefits Section, 25 Buick Street, Boston, MA 02215

Dependent Care Account Eligible Expenses

In general, the following rules apply to dependent care expenses:

The annual amount reimbursed may not exceed the earned income of the lower-paid spouse or $5,000, whichever is
less. If married and filing separate tax returns, you may not exceed $2,500.

Incurred expenses must be expenses that will allow you or your spouse to work or attend school and be for services
provided for the care of a dependent who is under age 13 and for whom you are entitled to take a dependent
deduction under Internal Revenue Code section 151(e), or a dependent who is physically or mentally incapable of
caring for himself or herself.

Expenses for day care and day camp programs are allowable, however, if program hours exceed the employee’s
working hours, submit ONLY that portion of the expense incurred for work-related hours. Overnight camp programs
are not allowable expenses.

Supporting Documentation

The following supporting documentation must be attached to this form:

           1.   Name of person receiving the service
           2.   Name and address of service provider
           3.   Amount charged
           4.   Date service was rendered
           5.   Provider’s Tax ID or Social Security Number

Complete the Provider Information for dependent care expenses on the front of this form. Also attach an original bill
or statement from the care giver indicating the date or period the services were rendered.

Rejected Reimbursement Claims

Reimbursement claims may be rejected for the following reasons:

           1.   Expense not incurred within the current plan year.
           2.   Expense not incurred within your dates of participation.
           3.   Expense not allowable according to IRS/Plan Regulations.
           4.   Dependent not eligible under IRS regulations.
           5.   Dependent’s name, date(s) and/or Provider’s ID Number or charges were not clearly shown on
           6.   Reimbursement claim form and supporting documentation were not originals.

If your expense is rejected, you may resubmit your claim with proper documentation on a new reimbursement claim
form for the next processing period.


   Service dates for reimbursable expenses must fall within the plan year. Reimbursement claims not
submitted during the plan year must be submitted to and received by Human Resources by no later than
March 31st following the end of the plan year. Please contact Human Resources for more information.

Please return claim forms to: Human Resources, Benefits Section, 25 Buick Street, Boston, MA 02215

To top