Adoption Assistance Reimbursement Claim Form

Stanford University offers eligible employees adoption assistance that reimburses up to $10,000 per adoption for "qualified adoption expenses." Any expenses incurred on or after the employee's first day of Stanford University employment, but not before September 1, 2001, are eligible for reimbursement consideration.

The adopted child must:

Be under the age of 18 at the time a "qualified adoption expense"* is paid or incurred and

Not be the child of the employee's spouse or domestic partner.

* indicates required fields.

Stanford University Employee’s Name: *

First *

Last *

SU ID *

Position *

Department *

Daytime Phone (e.g. 650-555-1212) *

Email *

Home Address *

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Spouse/Partner's Name:

First

Last

Spouse/Partner's Employer:

Dependent Information

Child's First and Last Name: *

Date of expected placement in home OR finalization of adoption: *

Is the child in your home? *

Yes

If the child is in your home, list the date of placement: *

If the child is not in your home, please provide an explanation: *

Expense Information

Please submit a copy of the order/contract paperwork that confirms the child's placement in your home or the finalization of the adoption, a list of all relevant adoption expenses, copies of the corresponding receipts, and if needed, an explanatory cover letter in the attachment fields below. Thank you.

Total $ Amount for Adoption Expenses: *

Upload File *

Upload File 2

I certify that I will attach all applicable documentation for reimbursement under Stanford University’s Adoption Assistance Program. I understand I must notify the WorkLife Office of any change regarding the adoption. I certify under penalty of perjury that all statements and documentation relating to this claim are complete and true. I understand that incomplete or inaccurate information may adversely affect my eligibility under this program up to and including repayment to Stanford University of any funds awarded, and/or may result in adverse employment consequences for myself. *

Yes

Connecting with Others: Are you interested in potentially sharing your adoption experience/insights with other faculty and staff members who are starting the adoption process? *

Yes

Additional Information

If you have any questions please email Melanie Rappa at mrappa@stanford.edu.