Dependent Care Account
Reimbursement Request Form
If Your Provider Does Not Provide You With A Receipt: Have your Provider complete this section.
Claimant Name Date of Care
Start Date
(within a single
Plan Year)
Date of Care
End Date
(within a single
Plan Year)
Provider Amount Claim
Ref #
01
02
03
04
If Your Provider Gives You A Receipt: Complete this section, and attach a copy of the receipt.
OR
Provider Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________________
City, ST, ZIP: _______________________________________________________________________________________
Tax Payer ID/SSN: _______________________________
Dependent Care for (Name and Age):_________________________________________________________________
Dates of Care (within a single Plan Year) Start Date: _____________________ End Date: _____________________
Amount Charged: $______________________________________
Provider Signature: _______________________________________________________ Date: _________________
Participant Authorization—By submitting this form to Lifetime Benefit Solutions, I certify that the information here is true and correct.
I authorize the above expenses to be reimbursed from my dependent care account.
I certify the expenses qualify as valid dependent care expenses under the terms of
the Plan.
I understand that the copy of my receipt will include Provider name, address, tax
ID/SSN, child’s name and age, dates of care, and amount charged.
I will keep copies of all documents submitted to Lifetime Benefit Solutions, for my
own personal records; Lifetime Benefit Solutions, is not responsible for retaining
copies of my receipts beyond the current Plan year.
I understand a qualifying dependent is a child under age 13, who is claimed as a
dependent on my federal income tax return (special rules apply for divorced
parents), a disabled spouse, and any other dependent on my tax return who
resides in my home and is physically or mentally disabled.
I certify these expenses have not previously been reimbursed and I understand
the expenses reimbursed may not be used to claim any federal income tax de-
duction or credit.
I agree to file IRS Form 2441 with my tax return and provide any required tax-
payer identification number.
Mail to: Lifetime Benefit Solutions, Claims Dept, PO Box 6509, Syracuse, NY 13217 or
Fax to: 877-256-7228.
Call Customer Service with questions at 800-327-7130.
*RE
Employer Name: ____________________________________________________________________________________
Participant Name (First, MI, Last): ______________________________________________________________________
Social Security Number: ______ - ______ - ____________
Address: ___________________________________________________________________________________________
City, ST, ZIP: ________________________________________________________________________________________
Date of Birth: _________/__________/__________ Phone Number (________) _____________________
Please notify your employer of any address change. Lifetime Benefit Solutions will not make address changes from this form.
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