Legal Adoption Form Request by ebx17632


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									                                                                            Adoption Assistance Plan (AAP)
                                                                             Reimbursement Request Form
                               Please read these instructions before completing the form.
 1. Complete all areas of Part 1 Employee Information.
 2. Complete all areas of Part 2 Child Information.
    • Name Print the child’s first, middle and last name.
    • Date of Birth Print the child’s date of birth (month, day, year).
    • Adoption of Child of Spouse or Domestic Partner Check Yes box if you are adopting your spouse’s or domestic
       partner’s child, otherwise, check No.
    • Spousal Adoption Check Yes box if your spouse or domestic partner is adopting your child, otherwise, check No.
    • Adoption of Child Who is a Relative Check Yes if the child you’re adopting is your relative, otherwise, check No.
    • If Adopted Child is 18 Years or Older indicate whether he or she is or is not capable of self-care.
    • Type of Adoption Check the box indicating whether your adoption was domestic or foreign.
    • Legal Adoption Date Print the date (month, day, year) the adoption was finalized.
 3. Complete all areas of Part 3 Expenses.
    • Date Print the date (month, day, year) the expense was incurred.
    • Amount Print the amount you paid for which you request to be reimbursed.
    • Explanation Print a brief description of the incurred expense.
 4. Read the Employee’s Certification for Reimbursement statement, then sign and date the form where indicated. Please
    keep a copy of this completed form for your records.
 5. Attach a copy of all receipts from paid invoices or cancelled checks for expenses listed in Part 3.
 6. Attach a copy of the final adoption decree.
 7. Mail the completed Reimbursement Request Form and attachments to the address on the back and allow two to four
    weeks for reimbursement approval and processing.

Reimbursements are made to UnitedHealth Group employees only, via regular paycheck. Payments may not be assigned to any other
person. Any expenses reimbursed from the AAP account cannot be claimed as a deduction or credit on your federal income tax return.

 Part 1 Employee/Spouse/Domestic Partner Information

 Employee Name:                                                   Social Security Number:

 Interoffice Address:                                             Employee ID Number:

 Work Phone: (          )                If applicable, name of spouse or domestic partner:

 Is your spouse or domestic partner an employee of UnitedHealth Group, its affiliate or subsidiary? (Note: domestic
 partners must satisfy eligibility criteria set forth in UnitedHealth Group’s Adoption Assistance Plan.)

  Yes ! If Yes complete line below. No !

      Spouse’s/Domestic Partner’s Social Security Number:         Spouse’s/Domestic Partner’s Employee ID Number:

 Are you a U.S. citizen? Yes ! No !

 Part 2 Child Information

 Name:                                                             Date of Birth:

 Are you adopting your spouse’s or domestic partner’s              Is your spouse or domestic partner adopting your child?
                                                                   Yes ! No !
 Yes ! No !

 Are you adopting a child who is a relative?                       If the adopted child is 18 years or older, is he/she physically
                                                                   or mentally incapable of self-care?
 Yes ! No !
                                                                   Yes ! No !

 Type of Adoption: Domestic ! Foreign !                            Adoption finalization date:


                                            Please review the reverse side of this form.
 Part 3 Expenses
 Eligible expenses include reasonable and necessary adoption fees, court costs, and attorney fees. For additional
 information about AAP eligible and excluded expenses, look on the Knowledge Base.
          Date                    Amount                                              Description

 Total Reimbursement
 Requested !!!

Employee’s Certification for Reimbursement
I certify that the expenses for reimbursement requested from the Adoption Assistance Plan were incurred by me, have been
paid by me, were not reimbursed by any other plan, and to the best of my knowledge and belief, are eligible for reimbursement
under my Adoption Assistance Plan. I will not use the expenses reimbursed through the Adoption Assistance Plan as
deductions or credits when filing my individual income tax return.
I understand that qualifying expenses reimbursed under the Adoption Assistance Plan are not subject to income tax
withholding, but are subject to FICA (Social Security and Medicare tax) and FUTA taxes. In addition, I understand that the
reimbursement amount will be reported in box 12 of my Form W-2, identified with the letter “T.” I further understand that the
reimbursement amount will not be included with my taxable wages in Box 1 of Form W-2.
If the reimbursement does not qualify for the adoption exclusion under Internal Revenue Service (IRS) rules, I understand that
I must make an adjustment on my tax return, and that I will be responsible for any taxes.

_______________________________________________________                     __________________________________________
 Employee Signature                                                          Date

          Make a copy of this completed form for your records, and mail the original along with copies of all eligible bills
             and receipts for which you expect to be reimbursed and a copy of the finalized adoption certificate to:

                                 Professional Services Group – Benefits
                                       UnitedHealth Group Center
                                  9900 Bren Road East – MN008-B216
                                         Minnetonka, MN 55343

For Human Capital Use Only

Total Approved Amount:                              Do expenses qualify for tax withholding? Yes ! No !

Authorized Approver Signature:                                    Date:


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