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THE UNIVERSITY OF TENNESSEE FLEXIBLE BENEFITS PLAN DEPENDENT CARE REIMBURSEMENT CLAIM FORM Employee Name (please print) I. D No. or Personnel No. Monthly Office Telephone Number Biweekly Expenses

How to fill out dependent care reimbursement claim

How to Fill out Dependent Care Reimbursement Claim:

1. Gather necessary documentation: Before filling out the dependent care reimbursement claim, ensure you have all the required documentation handy. This may include receipts or invoices from the dependent care provider, proof of payment, and any other supporting documents requested by your employer or insurance provider.
2. Obtain the claim form: Contact your employer or insurance provider to obtain the dependent care reimbursement claim form. This form will typically ask for basic information such as your name, address, and social security number, as well as details about the dependent care expenses you wish to be reimbursed for.
3. Fill out personal information: Start by filling out the personal information section of the claim form. Provide accurate details about yourself, including your full name, home address, and social security number.
4. Provide dependent information: If you have multiple dependents, make sure to indicate the specific dependent(s) for whom you are seeking reimbursement. Include their full names, dates of birth, and any other required information.
5. Specify the care provider: Indicate the details of the dependent care provider, such as their name, address, and phone number. You may also be asked to provide their tax identification number (if applicable) or other identification details.
6. Enter reimbursement amount: Clearly state the total amount you are seeking reimbursement for. This should match the eligible dependent care expenses you incurred during the specified reimbursement period.
7. Attach supporting documents: Carefully review the documentation requirements provided with the claim form. Attach all the necessary supporting documents, such as receipts or invoices, proof of payment, and any other supporting evidence required to validate your claim.
8. Review and submit: Take a moment to review the completed claim form for accuracy and completeness. Ensure that all the required fields have been filled out, signatures are provided where needed, and supporting documents are attached. Once you are confident everything is in order, submit the claim form as per the instructions provided by your employer or insurance provider.

Who Needs Dependent Care Reimbursement Claim:

1. Employees with dependent care expenses: The dependent care reimbursement claim is typically needed by employees who have incurred eligible expenses related to the care of their dependents. This can include expenses for child care, after-school programs, or care for elderly or disabled family members.
2. Those with employer-sponsored dependent care accounts: Some employers offer dependent care reimbursement accounts as part of their employee benefits package. Employees who have contributed to these accounts and wish to be reimbursed for their eligible dependent care expenses will need to submit a dependent care reimbursement claim.
3. Individuals with eligible dependents: Anyone who has dependents for whom they have paid for eligible dependent care services may need a dependent care reimbursement claim form. This can include parents, guardians, or other individuals who have financial responsibility for dependents and are seeking reimbursement for qualified care expenses.

For pdfFiller’s FAQs

What is dependent care reimbursement claim?

A dependent care reimbursement claim is a request for reimbursement for expenses related to caring for a dependent, such as a child or elderly family member.

Who is required to file dependent care reimbursement claim?

Employees who have a dependent care flexible spending account (FSA) and incur eligible dependent care expenses are required to file a dependent care reimbursement claim.

How to fill out dependent care reimbursement claim?

To fill out a dependent care reimbursement claim, employees typically need to provide details of the expenses incurred, including the date, the amount, and the name of the dependent care provider.

What is the purpose of dependent care reimbursement claim?

The purpose of the dependent care reimbursement claim is to request reimbursement for eligible dependent care expenses from the employee's FSA account.

What information must be reported on dependent care reimbursement claim?

Employees must report details of the dependent care expenses incurred, along with any supporting documentation, such as receipts or invoices.

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