Daycare Reimbursement Request Page 2
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1
2FILING A CLAIM
Eligible dependents are:
• Your children that live with you and are under thirteen (13) years of age; or
• Your tax dependents incapable of self-care that reside in your home at least eight (8)
hours per day.
A flexible benefits dependent care account is available to you and your spouse if
necessary for you both to remain gainfully employed or for you to remain gainfully
employed while your spouse maintains full-time student status. A dependent care
account is also available to single parents.
The care can be provided through babysitters, live-in care, and/or licensed day care
centers.
Ineligible expenses are:
• Expenses paid for care to your spouse or one of your children under the age of nineteen
(19).
• Schooling expenses for the kindergarten level and above.
• Overnight camp.
• Nursing homes.
• Meals or other expenses billed separately.
• Transportation from any source other than the provider.
You may attach a bill or a receipt from your provider to this claim form or simply have
your provider sign the front of this form on the appropriate line(s).
Eligible claims received must total at least $1.00 before a check will be mailed or an
electronic deposit initiated by Allegiance.
Save time! Direct deposit is a convenient and easy way to receive your flex
reimbursement - see
and sign up today!
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