Daycare Claim Form Page 2
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1
2HOW TO FILE YOUR REQUEST
Definition of Dependent Care:
Must be “for care of an eligible dependent by IRS regulations enabling you or your spouse to work or to
seek employment”
Definition of Eligible Dependents:
The IRS states an eligible dependent is less than 13 years old and living with you. An eligible dependent
may also include your mentally or physically impaired spouse/dependent/child who is living with you
and incapable of caring for him or her self.
*The provider of the care MUST declare the funds you pay them as income
DAYCARE
Fill out only if you are manually submitting claims throughout the
year
CLAIM FORM
Documentation must be attached
Sign the bottom of the claim form
RECURRING
DAYCARE
Enter amount paid to provider per week
Enter Begin Date of the recurring costs
Enter End Date of plan year or date no longer have daycare costs
Enter Dependents Name
Enter Dependents Date of Birth
Have Provider Sign Claim Form and enter Tax Id # or SS#
Sign the bottom of the claim form
10/12/2007
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Parent category: Education