ACCOUNT HOLDER INFORMATION
Last Name First Name
Employer / Program Sponsor's Name
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CERTIFICATION AND AUTHORIZATION
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CLAIMS FOR OUT-OF-POCKET EXPENSES
Dependent's Name
1 $
Provider's Name Out-of-Pocket Cost
Provider's SSN or Tax ID#
Date
Certifies services provided. Not required. Replaces need for receipt or other proof of service.
Dependent's Name
2 $
Provider's Name Out-of-Pocket Cost
Provider's SSN or Tax ID#
Date
Certifies services provided. Not required. Replaces need for receipt or other proof of service.
$
TOTAL THIS FORM
MORE EXPENSES? Complete another form.
Service End Date (MM/DD/YY)
Service Start Date (MM/DD/YY)
Service Start Date (MM/DD/YY)
Birth Month/Day (MM/DD)
Signature of Provider X
Service End Date (MM/DD/YY)
Signature of Provider X
YOU MUST HAVE PROVIDER SIGN FORM OR INCLUDE A RECEIPT OR OTHER APPROPRIATE PROOF
OF SERVICE FOR EACH AMOUNT ABOVE.
Dependent Care Accoun
Pay Me Back Claim Form
TOLL-FREE FAX: (877) 353 - 9236
Or, mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512
Child care Before/after school
Preschool Summer day camp
Au pair Senior day care
Other: __________________________
Child care Before/after school
Preschool Summer day camp
Au pair Senior day care
Other: __________________________
DO NOT USE A FAX
COVER SHEET
to ensure speedy processing.
www.wageworks.com
WW-DC-PMB (Jun 2008)
ID Code (last 4 digits)
*
*
Your ID Code is the last 4 digits of your Social Security Number, your Employee Number or other reference
number assigned by your program sponsor. Please check the enrollment instructions provided by your program
sponsor for more information about your ID Code.
I certify that the information on this page is accurate and complete. I am requesting reimbursement for work-related dependent care expenses incurred by an eligible
dependent (for a child under the age of 13 or other dependents that are physically and mentally incapable of taking care of themselves) while I was a participant in the plan.
These services have already been provided and I have not and will not seek reimbursement of this expense from any other plan or party. Use of this service indicates my
acceptance of the WageWorks User Agreement at www.wageworks.com (available upon registration; enter user name and password or click on First Time User? link).
