Adoption Assistance Request Form

Section  I: Employee Information

Employee name: ____________________________________________

Department: _______________________________________________

Phone number: _____________________________________________

E-mail address: ______________________________________________

Section II: Adoption Information

Adopted child's name: _________________________________________

Date of birth: ________________________________________________

Date of adoption*: ____________________________________________

*Please attach a copy of the adoption placement certificate or final adoption decree.

Section III: Eligible Adoption Expenses **

All expenses must be submitted within six months of the date the adoption was finalized. 

** Eligible expenses include adoption agency and placement fees, attorneys' fees/court costs, cost of temporary foster care for the child (during the adoption process), immunizations required for the adoption (during the adoption process and prior to the finalization of the adoption) and reasonable and necessary transportation and lodging directly associated with the adoption. (Section 137 of the Internal Revenue Code pertaining to adoption assistance programs)

Section IV: Employee Certification

I certify that the expenses included in this request are eligible adoption expenses and that I am responsible for payment of these expenses. I understand that it is my responsibility to verify with the Internal Revenue Service (IRS) or my tax consultant the tax implications of receiving this money, and that I assume all tax liability for this reimbursement.

Employee signature: __________________________          Date: ________________