Daycare Claim Form

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Remit To:
Plus Point Services
307 oak street
hood river, or 97031
PHONE: 541.386.1696
S125 Dependent Care Reimbursement
FAX: 541.386.2280
EMAIL:
Daycare Claim Form
Employee Information
Employer Name:
Daytime Phone:
Employee Name:
Employee ID:
Employee Address:
State:
Zip:
City:
Email Address:
PLEASE NOTE: Claims that are not listed on this from cannot be processed. You must complete each field below for each claim you are
seeking reimbursement for and attach supporting documentation.
Dependent Daycare Expense (Attach supporting documentation if provider does not sign form)
--- Provider’s Name
---- Address
Supporting documentation for dependent care expenses is
required only if provider does not sign this form. Otherwise,
--- Tax ID
---- Amount Billed
documentation must include the following:
--- Dependent’s Name
Date of Service
Name and Address of Dep Care
Name of Dependent
EIN or SSN# of Provider
Amount
Provider
From
To
Total Amount Requested:
DEPENDENT CARE PROVIDER’S VERIFICATION: I certify that the above charges are accurate as described
Provider Name: _________________
__________
Tax ID or SSN: ____________________________
Address: _________________________________________________________________________________
Provider’s Signature: ______________________
__________
Date: _________________________
Please Note: The daycare provider must declare this as income on their tax return.
Employee Confirmation
By signing this form I certify that the expenses for reimbursement listed above were incurred during the time specified for the care of a
qualified dependent(s) under age of 13 or for a qualified dependent(s) who is incapable of self-care. I certify that these expenses have not
previously been reimbursed by this or any other benefit plan, will not be reimbursed from any other source and will not be claimed as an
income tax deduction when filing an income tax return.
Employee Signature:
Date: _________________

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