Complete this form to meet the requirements for documenour day care expenses. This form, once completed, may act as your receipt
for expenses incurred.
Section D: Authorization *REQUIRED (PLEASE SIGN AND DATE)
INSTRUCTIONS
Completeorm. Remember to sign and datom of this form.
1. Ask your provider to completorm if a daycare receipt is not available.
2. online or mobile app claim or alert, you may use one of these secondary op
to send your documentao us. Please note, that Igoe cannot guarantee the security of any documentaovided to use via the below
methods while in transit to our organiza
• Email to flex@goigoe.com
• Fax to 800-456-9083
• OR Mail to Igoe Administrae Services, P.O. Box 501480, San Diego, CA 92150-1480
3. Please contact Pt Services at flex@goigoe.com, 1-800-633-8818, Opt# 1.
Dependent Daycare Reimbursement Request
and/or Provider Acknowledgement Form
Service Date
( mm/ dd/ yy )
’
- $
- $
- $
$
(To be completed by the daycare provider if a separate receipt is not available)
,
name of the provider, and provider’s Tax ID or SSN as listed above are correct.
Provider’s Signature: Date:
Section A: About You
Employer Name
Pt Name Number of pages Employee Number (If Applicable)
Home Address
Please check if this is a change in address
City State Zip
E-mail Address Phone Number
I that I am a in the plan from which I am reimbursement and that all expenses listed with this claim were
benefit plan or charged to my employer's Benefits Card (if applicable). I understand that I am fully responsible for the sufficiency, accuracy,
not, I understand that I may be liable for the payment of all related taxes including federal, state or city Income Tax on amounts
reimbursed. I further understand that NO TAX DEDUCTION IS PERMITTED FOR AMOUNTS FOR WHICH REIMBURSEMENT IS MADE. Having
agreed to all of the proceeding statements, I authorize the account associated with the plan selected to be reduced by the amount
requested and reimbursed to me according to my employer’s reimbursement schedule and method.
Employee Signature:
Date:
Clear Form
Clear Section B
Clear Section A
0.00
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