FY20 Faculty Child Care Assistance Program Reimbursement Claim Form

Assistance through this program will be paid through the standard payroll system and considered taxable income by the Internal Revenue Service.

* indicates required fields.

Reimbursements are processed 5 times per year. Claims received by the due date will be reimbursed on the 21st of the following month.

Please mark the appropriate reimbursement period deadline for this claim: *

Name *




Verification of Employment Status


My appointment status has not changed during this reimbursement period. *

Spouse or Partner's Name



Re-Verification for Spouse or Partner: He or she is *

Expense Information








Submit Receipts

Please compose an email to WorkLifeFinAssist@stanford.edu. Type "Secure:" at the start of the email subject line. Include -

- The names and ages of eligible children in your household, ages 5 and younger.
- Attach receipts using the following guide:

For claims that include center-based care, please provide a copy of your most recent account statement that shows payments that have been submitted to the vendor.

If you have an in-home child care provider, please use the sample receipt that was provided on the previous page in order to capture all of the necessary details. Please note that the child care provider must sign and date the form.

The child (or children) referenced in this claim is (are) my current tax dependent(s). *

I certify that I have attached all applicable source documents. I certify under penalty of prejury that all statements and documentation relating to this claim are true. I understand that incomplete or inaccurate information may adversely affect my child(ren)'s eligibility under this program, up to and including repayment to Stanford University of any funds awarded and/or may result in disciplinary action. *

Additional Information

If you have questions, please contact WorkLifeFinAssist@stanford.edu for additional support.