Fax: 877-641-5956
Phone: 501-941-5956
Cabot, AR 72023
P.O. Box 1513
Dependent Care Claim form
First Name
Last Name:
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:
For questions regarding your claims please call: 501-941-5956
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:__________________________________________________________
Print Form
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