State Street Adoption Assistance Plan
Reimbursement Request Form
Instructions
Eligibility for Reimbursement
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You may be eligible to receive up to $5,000 for qualified expenses related to the legal adoption of a child, provided
the adoption is finalized while you are an eligible employee of the company.
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You must be an active employee scheduled to work at least 20 hours per week at the time the adoption is finalized and
at the time of reimbursement.
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You may submit the reimbursement request once the adoption is final.
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If both adoptive parents are employed by State Street Corporation or one of its affiliated companies eligible for
adoption assistance benefits, the maximum benefit allowed is $5,000 per adopted child.
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The adopted child must be under the age of 18. Eligible adoptions include the adoption of stepchildren.
Eligible Expenses
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Private and public agency fees
Physical exams for adoptive parents
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Placement fees
Home study fees
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Reasonable travel expenses incurred while
Cost of child’s medical expenses required to finalize
completing the adoption process
adoption
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Legal fees
Ineligible Expenses, such as, but not limited to:
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Medical care and counseling for the birth
Legal fees for contested adoptions
mother
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Personal travel-related expenses, i.e., visas,
Post-adoption counseling services for the adopted child
passports, meals
and the adopting family
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Miscellaneous administrative expenses, i.e.,
Expenses claimed under the federal adoption expense
phone calls, postage, fax charges
tax credit
How to Apply for Reimbursement
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You pay for expenses and receive itemized bills or receipts. All bills and receipts must be in English or accompanied
by an English translation and in or converted to US dollars.
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Complete the Adoption Assistance Plan Reimbursement Request Form and return the completed form along with
copies of supporting bills or receipts and a copy of the Adoption Certificate to the Adoption Assistance Administrator,
GHR U. S. Benefits Planning Department, LCC 1E. Forms that are incomplete or missing proper documentation will
not be processed and will be returned to the applicant.
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Upon approval by State Street, reimbursement will be made in the next available payroll as a lump sum payment. No
deductions will be withheld except for required taxes. Payment will be made in the same manner as regular pay,
either as a direct deposit or a live check.
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Amounts paid under this plan will not be subject to federal and in most cases, state income tax withholding at the time
of reimbursement but will be subject to Medicare (FICA) and federal unemployment tax (FUTA). However, federal
tax rules require that any reimbursement for adoption expenses related to a stepchild must be considered taxable.
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Reimbursement will not be considered eligible pay for any other benefits, such as retirement contributions, life
insurance base, or long term disability base.
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Although the amounts are not subject to tax withholding at the time of reimbursement, some employees may not
qualify for the exclusion at the time of tax filing. Please consult your tax advisor with any questions regarding your
individual tax filing.
If you have any questions about the Adoption Assistance Plan, call
GHR Customer Service at (617) 985-8040.
Rev. 7/20/2007