Adoption Form - State Street Benefits Center Page 2
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2State Street Adoption Assistance Plan
Reimbursement Request Form
About You
Last Name
First Name
MI
Social Security Number
Daytime Phone
Department
Internal Address
Employee ID Number
About Your Adopted Child
(Attach a copy of the Adoption Certificate)
Adopted Child’s Last Name
First Name
MI
Social Security Number or Adoption
Taxpayer Identification Number
Date of Child’s Birth
Date of Final Adoption
Before adoption, is this child related to you or your spouse?
Yes
No
Relationship: _______________________________
Adoption Expenses
(Itemize eligible expenses below and attach supporting documentation)
Date Incurred*
Description of Expense*
Provider*
Dollar Amount*
$
$
$
$
$
$
* Please attach a copy of Adoption Certificate and supporting
Total Reimbursement Requested:
bills and receipts showing dates of service
$
Signature
I certify that the expenses for reimbursement requested from the Adoption Assistance Plan have been incurred in the process of
obtaining a legal adoption of the above-referenced child. Further, I certify that the above-referenced child has been legally placed in
my home for adoption and that documentation of this fact is enclosed. To the best of my knowledge, these expenses are eligible for
reimbursement. I hereby authorize the adoption agency, my attorney, or appointed judge in this adoption case to release any
information requested by State Street Corporation with respect to my claim. In the event of any overpayment, I hereby agree to
promptly reimburse State Street for the amount of the overpayment.
Employee Signature
Date
Keep a copy of this form for your records.
Return the completed form and accompanying documentation interoffice to:
Adoption Assistance Administrator, GHR U. S. Benefits Planning Department, LCC 1E
(If returning by outside mail, add: State Street / 2 Avenue de Lafayette, LCC 1E / Boston, MA 02111-1724)
For Benefits Use Only:
:
:
Approved by
Date
Rev. 7/20/2007
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