COMMUNITY SERVICE SOCIETY OF NEW YORK

Child Care Reimbursement Request

Instructions: Please complete the form carefully. Print or type all information. Attach any related bills or cancelled checks.

Part I: Employee Information and Certification

Name of Employee: Soc. Sec. Number

Reimbursement Request: Amount: $ Period:

Eligible Dependents: (must be under age 13)

Name Date of Birth

1.
2.
3.
4.

I certify that the information provided herein is correct.

Employee’s Signature: Date:

…………………………………………………………………………………………………………………………………..

Part II: Statement of Provider Services

Service Provider Name:

Provider Identification Number (Soc. Sec. Or Tax ID):
Address of Provider or Facility:
Telephone Number:
Dates of Service:
Cost of Service: $ per Total $

I certify that I have provided childcare services, at the fee indicated above, for the child (or children) named above.

Signature of Provider: Date:

………………………………………………………………………………………………………………………..

CSS will not assume any liability whatsoever for the acts or omissions of referral or child care agencies for services
provided.

Part III: Approval

Payroll /Benefits Administration Supervisor Date

Paid $
Amount Quarter Check Number Check Date