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REFLEX Annualized Dependent Care Reimbursement Form Phone: 1-877-267-3359 Fax: 1- 501-221-9074 *******PLEASE NOTE IF ADDRESS IS A NEW ADDRESS******* A. EMPLOYEE INFORMATION Name Social Security Number

How to fill out dependent care reimbursement form

How to fill out dependent care reimbursement form:

1. Gather all necessary documentation such as receipts and invoices for dependent care expenses.
2. Enter personal information including name, address, and contact details.
3. Provide details about your dependent(s) such as their name, date of birth, and relationship to you.
4. Specify the type of dependent care services you used (e.g., daycare, nanny services) and provide the name and address of the provider.
5. Indicate the dates when the dependent care services were provided and the total amount paid for each period.
6. Attach copies of all relevant receipts and invoices to support the expenses claimed.
7. Sign and date the form to certify the accuracy of the information provided.

Who needs dependent care reimbursement form:

1. Employees who have dependents and have incurred eligible dependent care expenses.
2. Individuals who participate in a dependent care reimbursement account offered by their employer.
3. Parents or guardians who have utilized dependent care services for their children or other dependents.

For pdfFiller’s FAQs

What is dependent care reimbursement form?

The dependent care reimbursement form is a document used to request reimbursement for expenses incurred for the care of dependents, such as children or elderly parents, while the individual is at work or attending school.

Who is required to file dependent care reimbursement form?

Employees who have dependent care expenses and wish to be reimbursed for those expenses are required to file the dependent care reimbursement form. This may vary depending on the employer's policies and eligibility criteria.

How to fill out dependent care reimbursement form?

To fill out the dependent care reimbursement form, you will need to provide personal information such as your name, address, and social security number. You will also need to provide details about your dependents, the care provider, and the expenses incurred. The form may also require supporting documentation, such as receipts or invoices.

What is the purpose of dependent care reimbursement form?

The purpose of the dependent care reimbursement form is to enable individuals to request reimbursement for eligible dependent care expenses. This can help individuals offset the cost of dependent care and make it more affordable.

What information must be reported on dependent care reimbursement form?

The dependent care reimbursement form typically requires information such as the names and ages of dependents, the name and address of the care provider, the amount of expenses incurred, and any supporting documentation.

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