Daycare Claim Form
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1
2Company Name________________________________________
DAYCARE REIMBURSEMENT REQUEST FORM
Last
First
NAME:
SS#:
MI
Address
City , State ZIP
ADDRESS:
PHONE
(
)
:
Please check if this is a new address
DAYCARE CLAIM FORM
DATE OF SERVICE
DEPENDENT
DEPENDENT
CLAIM
PROVIDER
*PROVIDER
FROM
TO
NAME
BIRTH DATE
AMOUNT
TAX ID#/SS#
NAME
$
$
$
$
Total:
*There is a $25 minimum check amount – Please make sure you sign the bottom of this form.
RECURRING DAYCARE REIMBURSEMENT REQUEST FORM
New Recurring
Change to Recurring
The charge for the care is $
per month, beginning on
/
/
& ending on
/
/
.
Dependent Name_________________________ Dependents DOB____________________
PLEASE NOTE: The amount reported on this form should be the actual amount paid to the provider, not the
amount deducted from your paycheck.
PROVIDER VERIFICATION
* Signature of Provider mandatory if no Federal Tax ID is given above or documentation attached.
I verify that the above charges are accurate as described.
_____________________________________
_____________________
____________________
Provider Signature
Federal Tax ID Number
Date
Please Note: The daycare provider must declare this as income on their tax return.
I agree that if the amount changes or if for any reason, such as illness or vacation, the expenses are not incurred as scheduled,
I will notify Benefit Advantage immediately in writing.
This claim form is only valid for the current plan year and will be posted to your Flexible Spending Account at the
end of the first full week of every month. Reimbursements to you will occur as funds are received by Benefit
Advantage from your employer.
Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.
Employee Signature:
Date: ____________________
Fax to: (920) 339-0038 or (920)-339-5736
or mail to: Benefit Advantage Inc.
P.O. Box 5546, De Pere, WI 54115-5546
To view your account online:
10/12/2007
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Parent category: Education