Adoption & Surrogacy Assistance Reimbursement Request

Full-time regular staff who meet the criteria listed below shall be eligible for reimbursement for eligible expenses related to the adoption process. For more information, contact the Employee Service Center by calling 615.343.4788

Information about you:
Name Name First Middle Last
Employee ID
Home Mailing Address Home Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Department
Email
Daytime Phone Number Daytime Phone Number - ### - ### ####
Information about your child:
Child's Name Child's Name First Last
Child's Date of Birth Child's Date of Birth / MM / DD YYYY
Adoption Agency or Institution
Contact
Agency Address Agency Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Agency Phone Number Agency Phone Number - ### - ### ####
Date Adoption Finalized Date Adoption Finalized / MM / DD YYYY
Upon finalization of the adoption, itemized receipts, a copy of the final adoption papers from the court and this completed form must be submitted to the Director of Benefits for review, approval and reimbursement. Allow a minimum of 14 business days for processing.

Qualified Expenses are: 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. It is intended that this Plan meet the criteria and conditions set forth in Section 137 of the Internal Revenue Code pertaining to adoption assistance programs.
Please enter the expense, date of expense, and amount
Total Expense Amount $ Dollars . Cents
Please upload required documentation

Attach Files
Does your spouse work at Vanderbilt?

Does your spouse work at Vanderbilt? Yes No
If yes, provide name and department
Have you received an Adoption Assistance from Vanderbilt for another child?

Have you received an Adoption Assistance from Vanderbilt for another child? Yes No
If yes, provide child's name
I certify that the information I provided on this form is true and complete. I further certify that the child I am adopting is not married and not my stepchild and that documentation submitted with this application is true and complete.
Employee Signature
Date Date / MM / DD YYYY

Adoption & Surrogacy Assistance Reimbursement Request

Adoption & Surrogacy Assistance Reimbursement Request

Information about you:

Information about your child:

I certify that the information I provided on this form is true and complete. I further certify that the child I am adopting is not married and not my stepchild and that documentation submitted with this application is true and complete.