I:\Document Master\Master Forms\DDC05.08.06.doc
For Internal Use Only: Plan Year 1 Plan Year 2
DEPENDENT CARE REIMBURSEMENT ACCOUNT CLAIM FORM
(If all the information is completed on this claim form, no additional documentation is required.)
EMPLOYEE:___________________________________________________ SOCIAL SECURITY #_________________
EMPLOYER: __________________________________________________ Email:_______________________________
HOME ADDRESS:_______________________________________________________________________________________
Please X if new address Street/Apt No. City State
HOME PHONE:_________________________________________ WORK PHONE:______________________
DAY CARE PROVIDED FOR:_____________________________________________________________________________
This is to certify that I have incurred Dependent Day Care expenses in the amount of ___________________
for the period beginning____________________________and ending_______________________________.
Signature of Day Care Provider:_______________________________________________________________________________
Federal Employer Identification Number or Social Security Number of Day Care Provider:________________________________
Address of Day Care Provider:________________________________________________________________________________
Please attach receipts to document the above information only if this form is not signed by the provider.
REMEMBER to retain a copy of this claim form for your records
CERTIFICATION: I certify the expenses on this Claim Form:
• are accurate and true
• are for a person covered under this Plan
• are eligible expenses which have not been previously reimbursed under this or any other benefit plan
• will not be claimed for an income tax credit.
Employee Signature:_______________________________________________ Date:_______________________________
Benefit Resources, Inc.
4775 E. 91st Street, Suite 100 Tulsa, OK 74137-2805
Phone: (918) 481-6161 1 (800) 339-7493
Fax: (918) 481-6181 · 1-(866) 364-7052
www.britulsa.com
You may email scanned claims to: claims@britulsa.com
