Dependent Care Verification Form

This form is to be completed by your provider after dependent care expenses have been incurred and should be used in place of dependent care documentation. Attach this form to an online or debit card claim via your online account or to a Claim Form. If your cost of dependent care per month exceeds your monthly payroll deductions, you can fill out a Recurring Dependent Care Request Form at the beginning of the plan year and be reimbursed as your payroll deductions post to your account.

Please note that this form does not replace the need to submit a dependent care claim. Rather, it is intended to accompany your dependent care claim and serve as a substitute for the documentation required to substantiate that claim. No reimbursements will be made if this form is not uploaded to a claim or accompanied by the appropriate form.