Adoption Assistance Reimbursement Request Form

To request reimbursement for adoption-related expenses, please complete this application, attach a copy of the adoption placement decree and receipts for all eligible expenses for which you are seeking reimbursement.

Employee Information:








Adoptee Information:



If so, please attach documentation.







Eligible Adoption Expenses:


$



$



$



$


Total Reimbursement
$

Tax rules do not require income tax withholding unless your family adjusted gross income exceeds $252,150. (If you are married, you must file a joint return to take the adoption credit or exclusion.) Please indicate below if income tax withholding should apply. You are not required to complete the income tax withholding information indicated below, however, if no box is checked, taxes will automatically be withheld. Adoption assistance is subject to Social Security and Medicare taxes regardless of your income and will be withheld. Consult IRS Publication 968 or your tax advisor for additional information.

Adoption assistance benefits are not considered federal or state taxable income to you unless your family adjusted gross income exceeds $252,150.

To maximize your use of this benefit, you may indicate below whether income tax withholding should be applied to your adoption assistance benefit:


I certify that the information indicated above is correct.

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