DAYCARE EXPENSE REIMBURSEMENT FORM
To ensure timeliness of reimbursement processing, please complete form in its entirety, sign and date, and
attach an itemized statement.
PLEASE CHECK ONE OF THE FOLLOWING:
Documentation attached accompanies this manual claim form.
Documentation attached is for a claim submitted online via
Documentation attached is for purchases made with my Benefits Card.
Social Security Number
Employee Email address
Employee Phone Number
Name and Address of
Tax ID or SS#
Date of Birth
Dates of daycare
Total amount of reimbursement requested $_________________
If a receipt signed by your daycare provider is not attached, please have your daycare provider sign below:
Daycare Provider Signature
I request reimbursement for the attached expenses under my employer’s flexible benefits plan. I certify that the
dependent care expenses were incurred to allow myself (and my spouse) to be employed outside the home
during this plan year. I understand that the dependent care expenses reimbursed from the Dependent Care
Account cannot be claimed as a Child Care Tax Credit on my Federal Income Tax Return.
Change of address? No Yes
CDS Administrative Services, LLC
PO Box 570
Willmar, MN 56201
Phone: (888) 388-1040
Fax: (320) 235-0988