Academic Student Employee (ASE) Child Care Reimbursement Form - California

ACADEMIC STUDENT EMPLOYEE (ASE) CHILD CARE REIMBURSEMENT
FOR UAW-REPRESENTED STUDENT EMPLOYEES
UBEN 254 (R9/14) University of California Human Resources
Submit your completed form
to your hiring department
personnel office.
SEE REVERSE FOR PRIVACY NOTIFICATIONS
RETN: 5 years
EMPLOYEE’S SIGNATURE
I certify that: 1) I have incurred these expenses and have not previously requested payment for them from any source; 2) I have met all the
requirements for dependent care expenses (including as required by to the Internal Revenue Code); 3) under penalty of perjury the above
information is true to the best of my knowledge.
SIGNATURE (must be an original; not a photocopy) DATE
TOTAL AMOUNT TO BE REIMBURSED
( )
PERSONAL INFORMATION
EMPLOYEE’S NAME (Last, First, Middle Initial) EMPLOYEE ID NO. CAMPUS
ADDRESS (Number, Street) HIRING DEPARTMENT HOME PHONE
(City, State, ZIP) WORK PHONE
DEPENDENTS
DEPENDENT NAME RELATIONSHIP BIRTHDATE
DEPENDENT NAME RELATIONSHIP BIRTHDATE
DEPENDENT NAME RELATIONSHIP BIRTHDATE
DEPENDENT CARE INFORMATION
( )
FOR CAMPUS/LOCATION USE ONLY—Hiring department personnel
office signature at right certies that the form is complete, that the
employee has/had an appropriate appointment as an ASE and that
applicable documentation is attached.
If you are a UC academic student employee represented by the UAW,
use this form to request reimbursement of your eligible child care
expenses under the Academic Student Employee (ASE) Child Care
reimbursement program. For eligibility, see the Academic Student
Employee Child Care Reimbursement Program Factsheet, at
ucnet.universityofcalifornia.edu/forms/pdf/ase-child-care-
reimbursement-program.pdf.
A qualied dependent is a child in the custody of an ASE who is 12
years old or younger on July 1st. During the regular academic year, the
reimbursement limit is $900 per quarter or $1,350 per semester. During
a summer session(s), the limit is $900 irrespective of the number of
summer sessions in which an ASE is employed. A child care provider
must have a valid tax identication or Social Security number.
Deadline
Reimbursement requests for expenses must be submitted after the
expenses are incurred. Reimbursement requests should be submitted
via this form based on campus specied deadlines but no later than the
last day of the following term.
Payments under this program are subject to Federal, State and FICA
taxes, if applicable. Federal tax withholding will be 25 percent and state
tax withholding will be 6 percent.
DEPENDENT CARE PROVIDER TAXPAYER ID NO. DATES OF SERVICE
(FROM–TO)
AMOUNT OF INCURRED
EXPENSES (Attach a copy
of documentation)
AMOUNT TO BE
REIMBURSED
1. NAME
$
$
ADDRESS (Number, Street)
FALL SEMESTER SPRING SEMESTER SUMMER SESSION
FALL QUARTER WINTER QUARTER SPRING QUARTER
(City, State, ZIP)
2. NAME
$
$
ADDRESS (Number, Street)
FALL SEMESTER SPRING SEMESTER SUMMER SESSION
FALL QUARTER WINTER QUARTER SPRING QUARTER
(City, State, ZIP)
3. NAME
$
$
ADDRESS (Number, Street)
FALL SEMESTER SPRING SEMESTER SUMMER SESSION
FALL QUARTER WINTER QUARTER SPRING QUARTER
(City, State, ZIP)
SIGNATURE
HIRING DEPARTMENT PERSONNEL OFFICE
AUTHORIZES PAYMENT TO ASE AND INITIATES
PAYMENTS FOLLOWING CAMPUS GUIDELINES.
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