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Dependent Care Account Reimbursement Request Form If Your Provider Does Not Provide You With A Receipt: Have your Provider complete this section. Claimant Name Date of Care Start Date (within a single Plan Year) Date of Care End Date (within a single Plan Year) Provider Amount Claim Ref # 01 02 03 04 If Your Provider Gives You A Receipt: Complete this section, and attach a copy of the receipt. OR Provider Name: Address: City, ST, ZIP: Tax Payer ID/SSN: Dependent Care for (Name and Dates of Care (within a single Plan Year) Start Date: End Date: Amount Charged: Provider Signature: Date: Participant Authorization—By submitting this form to Lifetime Benefit Solutions, I certify that the information here is true and correct. authorize the above expenses to be reimbursed from my dependent care account. certify the expenses qualify as valid dependent care expenses under the terms of the Plan. understand that the copy of my receipt will include Provider name, address, tax ID/SSN, child’s name and age, dates of care, and amount charged. will keep copies of all documents submitted to Lifetime Benefit Solutions for my own personal records. understand a qualifying dependent is a child under age 13, who is claimed as a dependent on my federal income tax return (special rules apply for divorced parents), a disabled spouse, and any other dependent on my tax return who resides in my home and is physically or mentally disabled. certify these expenses have not previously been reimbursed and I understand the expenses reimbursed may not be used to claim any federal income tax de- duction or credit. agree to file IRS Form 2441 with my tax return and provide any required tax- payer identification number. Mail to: Lifetime Benefit Solutions, Claims Dept, PO Box 211126 Eagan, MN 55121 or Fax to: [PHONE REDACTED]. Call Customer Service with questions at [PHONE REDACTED]. *RE Employer Name: Participant Name (First, MI, Last): Social Security Number: - - Address: City, ST, ZIP: Date of Birth: Phone Number Please notify your employer of any address change. Lifetime Benefit Solutions will not make address changes from this form. R201 03/19 SIGN