info@consolidatedadmin.com
Fax: 877-641-5956
Phone: 501-941-5956
Cabot, AR 72023
P.O. Box 1513
www.consolidatedadmin.com
Dependent Care Claim form
First Name
Last Name:
Address:
SSN
Employer
Check here if new address
Please Itemize each expense on form
provided, if you have more expenses than
form allows please attach separate form.
Date of Service Dependent Name & Age Provider Name, Tax Id & Address Amount
I certify that the statement and information on this claim form are accurate and true.
I also certify that I am claiming reimbursement for only eligible expenses incurred during the plan year and are for eligible participants.
I certify that these expenses have not been or will not be reimbursed from any other source.
I assume all liability for taxes and penalties out of any disallowed contribution/reimbursement
Total Expense
Signature: Date:
Mail claims to: P.O. Box 1513, Cabot AR 72023; Fax claims to: 877-641-5956; or E-mail claims to: info@consolidatedadmin.com
For questions regarding your claims please call: 501-941-5956
Date
Please have your day care provider sign this form on the line below or provide a receipt for the services
Signature of day care provider:__________________________________________________________
click to sign
signature
click to edit
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