Health and Dependent Care Reimbursement - Wilkes University - wilkes 2025

1. Click ‘Get Form’ to open the Health and Dependent Care Reimbursement form in the editor.
2. Begin by entering your effective date at the top of the form. This is crucial for processing your reimbursement accurately.
3. Fill in your full name, Social Security number, and address in the designated fields to ensure proper identification.
4. Provide your date of birth as requested. This information helps verify your identity.
5. In the Direct Deposit Program section, enter your financial institution's name, nine-digit ABA routing number, and bank account number. Choose whether this account is a checking or savings account.
6. Input your email address for confirmation of funds transfer to receive notifications about your reimbursements.
7. Sign and date the form at the bottom to authorize participation in the Direct Deposit Program. Ensure you understand that you will not receive paper explanations of benefits.
8. Finally, return this completed election form to Human Resources for processing.

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