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Dependent Care Reimbursement Account Request form - UMR 2026
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- Click ‘Get Form’ to open the Dependent Care Reimbursement Account Request form in the editor.
- Begin by filling out Section B, Employee Information. Enter your last name, first name, employee identification number, and contact details including phone number and email address.
- In Section C, Dependent Care Expenses, list the dates of service for care provided. Ensure you include the daycare provider's name and Tax ID number along with the amount requested for each service.
- Total your reimbursement request at the bottom of Section C. Remember to attach an itemized bill from your provider that includes all required information as specified in the instructions.
- Finally, complete Section D by certifying that all expenses meet eligibility criteria. Sign and date the form before submitting it online or via fax/mail as instructed.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 4 Satisfied (60 Votes) |
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You can file claims online, or fax completed claim form supporting documentation toll free to 877-390-4782. . You can also mail the completed form Read more
HEALTH CARE DEPENDENT CARE. REIMBURSEMENT REQUEST. EMPLOYEE INFORMATION. NAME: UMR MEMBER ID/SSN #:. PHONE #:. CHECK HERE IF NEW ADDRESS. EMPLOYER NAME:.Read more