Claim Completion Guidelines:

1. All personal information must be filled out completely including name, address, social security number and company name.  If there has been a recent address change, the address change box must be marked.
2. Each expense must be listed individually including date of service, type of service, person receiving service and amount paid out of pocket for each expense.
3. Daycare expenses must also be listed individually including span of service dates, service provider information, child’s name & age and amount paid for services.
4. To be valid, the claim form must be signed and dated

All supporting receipts, statements, etc. must include the following:

1. Date of service
2. Summary of services provided, item purchased, etc.
3. Amount paid out of pocket (after insurance has paid – if applicable)
4. Name of service provider
5. Name of the person receiving the services

(Copies of canceled checks or credit card receipts cannot be accepted because they do not meet the above criteria.)