*Information required below:
Surrogate's Full Name:*
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Date of Embryo Transfer* (Real or Scheduled or if Unknown just put "unknown"):
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Address Check will be Mailed to:*
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If Applicable, Number of Weeks Pregnant on the 1st of the Upcoming Month:*
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Email Address:*
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Contact Phone Number: * XXX-XXX-XXXX
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ITEMS REQUESTED FOR PAYMENT:
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Monthly Non-Accountable Expense Allowance:
(1st pay after contract notarized by Surro & IPs for following month **contract may vary**)
Amount $:
Identify Paragraph/Section in Contract authorizing this payment:
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Monthly Pregnancy Compensation Due:
(1st pay after IVF HCG/Heartbeat Confirmation letter for following month **contract may vary**)
Amount $:
Identify Paragraph/Section in Contract authorizing this payment:
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Monthly Twin/Triplet Compensation Due:
(1st pay after 16th week Pregnant for following month **contract may vary**)
Amount $:
Identify Paragraph/Section in Contract authorizing this payment:
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Mileage Reimbursement (round trip):
(from prior period to 15th current month - Need MapQuest **contract may vary**)
miles
mile base
cents per mile ""
Date(s) and purpose for mileage reimbursement requested:
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Identify Paragraph/Section in Contract authorizing this payment:
Childcare Reimbursement:
(ONLY for bed-rest, from 15th last month to 15th current month - Need receipts/MDO letter **contract may vary**)
Amount $:
Date(s) and purpose for childcare reimbursement requested:
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Identify Paragraph/Section in Contract authorizing this payment:
Monthly Counselling Appointment:
(for current month - ONLY once monthly **contract may vary**)
Amount $:
Date(s):
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Identify Paragraph/Section in Contract authorizing this payment:
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Maternity Clothing Allowance Due:
(1. Singleton: pay after 14th week)(2. Twins: 1st pay after 12th week / 2nd pay after 24th week **contract may vary**)
Amount $:
Current # Wks. Pregnant
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Identify Paragraph/Section in Contract authorizing this payment:
Embryo Transfer fee or IUI Fee:
(pay for current month transfer (ONLY transfer been done) **contract may vary**)
Amount $:
Date of procedure:
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Identify Paragraph/Section in Contract authorizing this payment:
Start of Injectable Medications Fee:
Amount $:
Date of Start:
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Identify Paragraph/Section in Contract authorizing this payment:
Lost Wages Reason:
(ONLY for bed-rest, IVF appts up to 5 days, or after delivery bedrest - Need 3 recent paystubs, or/and MDO letter, or/and EDD statement - **contract may vary**)
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Date(s) being Reimbursed:
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Hourly Pay:
hours
per hour ""
Identify Paragraph/Section in Contract authorizing this payment:
Life Insurance Premium:
(NOT included in monthly check, will be separately processed)
Amount $:
Identify Paragraph/Section in Contract authorizing this payment:
Housekeeping Needed:
(ONLY for 3rd trimester or bed-rest - Need receipts and MDO letter **contract may vary**)
Bedrest Dates:
Reason:
Amount to be Reimbursed for Housekeeping $:
Identify Paragraph/Section in Contract authorizing this payment:
Other Misc. Reimbursements/Funds Requested:
(Any other reimbursement and requests, included but not limited: massage, husband lost wages, breast milk, C-section, drop cycle fee - Need receipts or valid documents - **contract may vary**)
Reason:
Amount $:
Date(s) of Occurrence:
Identify Paragraph/Section in Contract authorizing this payment:
Final Payment (Please check this box if this is your final payment)
I, * ,hereby state that the amounts listed on page one and two of this form are due to me according to the contract I have signed with my Intended Parent(s) and that I will email any and all receipts/invoices pertaining to said fees to this form and that I fully understand that all reimbursements are to be approved prior to release of funds. Any funds that are owed as a result of bedrest, disability or medical condition requires a copy of doctor�s note on file. I understand that any missing receipts or late requests may result in a delay or denial of request. My electronic signature below is my valid signature, and is binding.
Note that lost wages beyond 7 days requires submission to State Disability/Employment Development Department for benefits request and that reimbursement is for net lost wages not covered by the State. Claim forms are available through your Obstetricians office.
Please note: the amount(s) listed on this form are subject to review and change.
Signature:* Date:* MM-DD-YYYY