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Important: Please print clearly and be sure all sections are complete to avoid delays in processing. Mail the Adoption Assistance Reimbursement Form directly to the Life Programs Administrator along with all the original receipts. Each receipt must show the dates and nature of the services provided. Reimbursement forms will not be processed without original receipts. Keep photocopies for your personal records. Questions? Please contact the Employee Service Contact Centre at 1-866-214-0977 or send an email to ESHelp/CanWest/IBM or eshelp@ca.ibm.com
A Employee Information
____________________________________________ Employee Name _____________________________________________ Name of the child _____/______/______/______ Employees Internal Address ________ (____)__________ Serial # Business Phone (____)__________ Home Phone
Is assistance towards these charges provided from any federal, provincial or local government agency, private organization or other source? (Y/N) ____ If Yes, please provide details :_ _________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
D Privacy Information
The information collected in the Refund Form is kept confidential and is not disclosed to any other source. For more information please review IBM's Privacy Policy posted in the W3
Mailing Instructions Keep a copy of your form and receipts for your records
Life Programs Administrator (B2/3600/MKM) IBM Canada Ltd. 3600 Steeles Avenue East Markham, Ontario L3R 9Z7