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SANTA ROSA COUNTY FLEXIBLE BENEFITS PLAN DEPENDENT CARE REIMBURSEMENT CLAIM FORM Please check if address change Social Security No: Participants Name: Daytime Telephone Number: Participants Address:
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How to fill out dependent care reimbursement

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How to fill out dependent care reimbursement:

01
Check your eligibility - Before filling out the dependent care reimbursement forms, make sure you are eligible for this type of reimbursement. Generally, employees who have a dependent child under the age of 13 or a dependent with special needs who requires care can qualify for this benefit.
02
Gather necessary information - Collect all the essential information required to complete the dependent care reimbursement form. This may include details such as your dependent's name and birthdate, the name and address of the care provider, the amount paid for care services, and any receipts or invoices supporting your expenses.
03
Obtain the reimbursement form - Obtain the dependent care reimbursement form from your employer's Human Resources department or through your employee benefits portal. If you are unsure of where to find the form, reach out to HR for assistance.
04
Fill out the personal information section - Start by providing your personal information, including your name, address, social security number, and employee identification number. This helps ensure that the reimbursement is correctly processed to your account.
05
Provide dependent information - Supply the necessary information about your dependent(s), such as their name, date of birth, and relationship to you.
06
Enter care provider details - Fill in the name, address, and contact information of the care provider(s) who looked after your dependent. This may include daycare centers, babysitters, or licensed caregivers. Double-check the accuracy of the information you provide.
07
Specify the reimbursement period - Indicate the period for which you are seeking reimbursement. This typically includes the start and end date of when you incurred the child care expenses.
08
Fill in expense details - Enter the amount you paid for each expense related to dependent care. Include the type of service provided, such as daycare, after-school care, or summer camp. Attach supporting documentation, such as receipts or invoices, to validate the expenses claimed.
09
Review and submit - Review the filled-out form to ensure accuracy and completeness. Make sure you have included all necessary attachments. Sign and date the form as required, and submit it according to the process specified by your employer. This may involve submitting a physical copy or uploading it electronically.

Who needs dependent care reimbursement:

01
Employees with dependent children - Dependent care reimbursement is typically available to employees who have dependent children under the age of 13. This benefit helps offset the cost of child care expenses incurred while the employee is at work.
02
Employees with dependents requiring special care - In addition to dependent children, employees who have dependents with special needs, regardless of age, may also be eligible for dependent care reimbursement. The care provided must be necessary to enable the employee to work or actively seek employment.
03
Individuals with approved employer programs - Dependent care reimbursement is often offered as part of employee benefits packages. Therefore, individuals who work for employers that provide this benefit may be eligible to receive reimbursement for their dependent care expenses. It is essential to review the specific terms and conditions of your employer's program to determine eligibility.
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Dependent care reimbursement is a benefit that allows employees to set aside pre-tax income to pay for eligible dependent care expenses, such as child care or elder care.
Employees who have dependent care expenses and are enrolled in a dependent care reimbursement program are required to file.
To fill out dependent care reimbursement, employees need to submit a claim form along with receipts for eligible expenses.
The purpose of dependent care reimbursement is to help employees save money on dependent care expenses by using pre-tax income.
Employees must report the amount of expenses incurred for dependent care, along with receipts and any other required documentation.
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