Dependent Care Claim Form Page 2
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2PO Box 5546 De Pere, WI 54115-5546
Phone (800) 686-6829
Fax (920) 339-0038
E-mail:
HOW 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 that 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
CHECKLIST
Fill out only if you are manually submitting claims throughout the year
Documentation must be attached
Sign the bottom of the claim form
The provider MUST sign the claim form or include a tax id in order to process the claim.
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