Form Ww-Dc-Pmb - Dependent Care Pay Me Back Claim Page 2

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Dependent Care
Pay Me Back Claim Form
File claim online - Join the growing majority of participants who submit their claim
online for faster service. Log in to your account at to file your
claim electronically and upload your documentation.
File claim via fax or mail - Claim forms may also be filed either via fax or US Mail and sent
to the following locations:
Fax: 877-353-9236, US Mail: CLAIMS ADMINISTRATOR, P.O. Box 14053, Lexington, KY, 40512
Claim processing time - Claims will be processed within 2 business days after WageWorks receives the
form. You may check the status of your claim by logging into your account at .
ACCOUNT HOLDER:
Last Name
First Name
Employer Name
* ID Code is the last 4 digits of your Social Security Number, your Employee ID number or other reference number
assigned by your employer. Please check the enrollment instructions provided by your program sponsor for more
information about your ID Code.
ID Code*
Zip Code
SERVICE DATES
DEPENDENT NAME, RELATIONSHIP TO ACCOUNT HOLDER
OUT-OF-POCKET
PROVIDER NAME
(Start and End Dates)
AND TYPE OF SERVICE
COST
(MM/DD/YY)
Dependent Name: ______________________________________________________
Relationship to Account Holder:
Type of Service:
Spouse
Child Care
Signature of Provider:
$
Qualifying Child
Preschool
,
.
Qualifying Relative
(Replaces the need for other proof of service.)
Before/After school
Other __________________
Senior day care
Au pair
Summer day camp
Dependent Name: ______________________________________________________
Relationship to Account Holder:
Type of Service:
Spouse
Child Care
Signature of Provider:
$
Qualifying Child
Preschool
,
.
Qualifying Relative
Before/After school
(Replaces the need for other proof of service.)
Other __________________
Senior day care
Au pair
Summer day camp
Dependent Name: ______________________________________________________
Relationship to Account Holder:
Type of Service:
Child Care
Spouse
$
Signature of Provider:
Preschool
Qualifying Child
,
.
Qualifying Relative
Before/After school
(Replaces the need for other proof of service.)
Other __________________
Senior day care
Au pair
Summer day camp
Dependent Name: ______________________________________________________
Type of Service:
Relationship to Account Holder:
Spouse
Child Care
$
Signature of Provider:
Preschool
Qualifying Child
,
.
Before/After school
Qualifying Relative
(Replaces the need for other proof of service.)
Other __________________
Senior day care
Au pair
Summer day camp
$
More expenses? Please complete another form.
CLAIM FORM TOTAL:
,
.
CERTIFICATION AND AUTHORIZATION:
I certify that the information on this page is accurate and complete. I am requesting reimbursement for work-related dependent care expenses
incurred by an eligible dependent (for a child under the age of 13 or other dependents that are physically and mentally incapable of taking care of themselves) while I was a participant in the
plan. These services have already been provided and confirm that by requesting reimbursement here that I have not and will not seek reimbursement of this expense from any other plan or
party. Use of this service indicates my acceptance of the WageWorks User Agreement at (available upon registration; enter username and password or click on First Time
User? link).
WW-DC-PMB (Nov 2012)

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