Complete this form to request automatic reimbursement from your Dependent Care Assistance Plan (DCAP) account.
Contributions will be reimbursed to you on a per-pay-period basis. By completing this form you will not need to provide continuing documentation. Please complete all fields and include appropriate documentation stating your child will be attending throughout the year or specific time frames. All information must be completed by you and the care facility to receive reimbursement.
Note: This form will not be processed without both your signature and the care provider’s signature.
