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<br /> <br />TML Intergovernmental Employee Benefits Pool <br />PO Box 140167 <br />Austin, Texas 78714-0167 <br />Fax: (512) 719-6505 <br /> <br />IITML <br /> <br />~ Intergovernmental <br />Employee Benefits <br />Pool <br /> <br />DEPENDENT CARE REIMBURSEMENT FORM <br /> <br />Employer Name Employer Group # <br />Employee Name Social Security # <br />Street Address City State Zip Code o Check here if new <br /> <br />Name of Individual or <br />Organization providing <br />Dependent Care Services <br /> <br />Tax ID <br />or SS# <br /> <br />Date <br />Incurred <br /> <br />Amt to be <br />Reimbursed <br /> <br />Expense for care <br />of: (Name) <br /> <br />$ <br /> <br />Name <br /> <br />$ <br /> <br />Address <br /> <br />$ <br /> <br />Name <br /> <br />Total $ <br /> <br />Employee Signature Date <br /> <br />AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are <br />dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses <br />incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible. <br />Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant <br />change in cost or coverage of my health plan or my spouse's health plan or separation from service as prescribed by IRS rules. If a change in <br />family status occurs, you have 31 days from the occumnce to change or revoke your election. Furthermore, I hereby authorize my employer to <br />transfer my required health benefits contribution on a monthly basis to the TML Intergovernmental Employee Benefits Pool. <br /> <br />StatemeIlfofCertification:lt:e7'tijythatIh~vep~pyid~qiqE7'elqr; , . ....," . .,c <br />dependenljfrom to ... yy,bharg~fd;'thY1,jktvic~,~a$Yi^ .......... <br /> <br />,:".,.;.)":':"':'",!,:,:: <br /> <br />^. .. (l~~~QI{iJ;rChJJ(Ji'l!hi.~r, <br /> <br />~': '>,';>{;~>:',:>","" ',- , ",,", ,A':'",-, <br />J ,.'" ",',,'.... ":' ~.>! ' '. <br /> <br /> <br /> <br />Name and Address of Provider <br /> <br />Provider's Signature <br /> <br />Tax ID or SS# <br /> <br />CONFIDENTIALITY NOTICE: The infonnation contained in this transmission, including any attachments, is for the sole use of the intended <br />recipient(s) and may contain confidential and privileged infonnation. Any unauthorized review, use, disclosure, or distribution is prohibited by <br />Federal law. If you are not the intended recipient of this message, you are notified that you may not disclose, print, copy, or disseminate this <br />infonnation. If you have received this transmission in error, please reply to the sender and delete or destroy the message. Unauthorized <br />interception of this transmission may be a violation of criminal law <br />