Dependent Care Account - JHU Benefits Site - muskingum 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Account Holder Information' section. Enter your last name, first name, ID code (last 4 digits), employer's name, zip code, and birth date in MM/DD format.
3. In the 'Certification and Authorization' section, read the statement carefully. By signing, you confirm that all information is accurate and that you are requesting reimbursement for eligible dependent care expenses.
4. For each dependent care expense, complete the 'Claims for Out-of-Pocket Expenses' section. Provide details such as the type of care (e.g., child care, preschool), dependent's name, provider's name, service start and end dates, provider's SSN or Tax ID#, and out-of-pocket cost.
5. Ensure that the provider signs where indicated. This signature certifies that services were provided and can replace the need for additional proof of service.
6. Finally, calculate your total expenses at the bottom of the form. If you have more expenses to claim, complete another form as needed.

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