INSTRUCTIONS: REQUEST FOR REIMBURSEMENT PREFERRED DEPENDENT CARE ACCOUNT
Alabama public employees enrolled in the state PEEHIP program and who have a flexible account for dependent care can use the form discussed in this article to apply for reimbursement. This document may be obtained from the website maintained by the Retirement Systems of Alabama.
Request For Reimbursement Preferred Dependent Care Account Step 1: Section 1 concerns information about the employee. Enter your first name, middle initial and last name on the first line.
Request For Reimbursement Preferred Dependent Care Account Step 2: Enter your date of birth and preferred blue account number on the second line.
Request For Reimbursement Preferred Dependent Care Account Step 3: Enter your company name on the third line.
Request For Reimbursement Preferred Dependent Care Account Step 4: Enter your work and home phone numbers on the fourth line.
Request For Reimbursement Preferred Dependent Care Account Step 5: Section 2 concerns documentation of the services for which you are seeking reimbursement. You can document up to four separate instances of dependent care for which you are seeking reimbursement. In the column on the left for each one, fill in the appropriate oval to specify whether you are seeking reimbursement concerning child day care, adult day care, before and after school care, or other eligible dependent care.
Request For Reimbursement Preferred Dependent Care Account Step 6: Enter the first name of the dependent.
Request For Reimbursement Preferred Dependent Care Account Step 7: Enter the last name of the dependent.
Request For Reimbursement Preferred Dependent Care Account Step 8: Enter the date of birth of the dependent.
Request For Reimbursement Preferred Dependent Care Account Step 9: Enter the age in years of the dependent.
Request For Reimbursement Preferred Dependent Care Account Step 10: Enter the beginning and ending dates during which this care was provided.
Request For Reimbursement Preferred Dependent Care Account Step 11: Enter the amount of the cost of the care.
Request For Reimbursement Preferred Dependent Care Account Step 12: Total the amount of the cost of care where indicated.
Request For Reimbursement Preferred Dependent Care Account Step 13: In section 3, give the provider's name and Social Security number or taxpayer ID.
Request For Reimbursement Preferred Dependent Care Account Step 14: Sign and date the bottom of the form.