Form

Employee Email*

Please use your work email address when submitting your reimbursement. We cannot accept requests from personal emails.

Employee First Name*

Employee Last Name*

Company Name*

Dependent/Child 1 First Name*

Dependent/Child 1 Last Name*

Dependent/Child 1 Birthdate*

Year/Month/Day

Dependent/Child 2 First Name

Dependent/Child 2 Last Name

Dependent/Child 2 Birthdate

Year/Month/Day

What are you using your Care Cash for?*

Child Care

Elder Care

Please share more information:*

Care Start Date*

Year/Month/Day

Care End Date*

Year/Month/Day

Care Start Time*

e.g. 9 AM

Care End Time*

e.g. 5 PM

Location/Type*

In Home - Family Member

In Home - Private Caregiver

Onsite Licensed Child Care

Other

Care Provider*

Please provide the name and contact information of your care provider

Care Cash Reimbursement Amount*

You are eligible to submit up to $100 of your backup care costs per day