Form 10-10152 Reimbursement Request for Qualifying Adoption Expenses

REIMBURSEMENT REQUEST FOR
QUALIFYING ADOPTION EXPENSES
Please read Privacy Act statement and Instructions on pages 2 and 3 before completing form.
SECTION I - GENERAL INFORMATION
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious,or fraudulent statement or representation.
(See 18 U.S.C. 287 and 1001).
1. VETERAN'S NAME (Last, First, Middle Name)
4. DATE OF BIRTH (mm/dd/yyyy)

3. GENDER
MALE

2. SOCIAL SECURITY NUMBER

FEMALE

7. PERMANENT ADDRESS (Street)

5. HOME TELEPHONE NUMBER

6. MOBILE TELEPHONE NUMBER

(Include area code)

(Include area code)

8. CITY

9. STATE

10. E-MAIL ADDRESS

11. CURRENT MARITAL STATUS
MARRIED

SEPARATED

DIVORCED

WIDOWED

NEVER MARRIED
12. ARE YOU A “COVERED VETERAN”? (SEE DEFINITION)

YES

NO

IF YES, COMPLETE THE REST OF THIS FORM

13. ANY PREVIOUS REIMBURSEMENT OF ADOPTION EXPENSES CLAIMED FROM VA IN CURRENT CALENDAR YEAR?

YES

NO

SECTION II - SPOUSE INFORMATION
14. IS YOUR SPOUSE A “COVERED VETERAN”? (SEE DEFINITION)

YES

NO

IF YES, COMPLETE BLOCKS 15 AND 16.

15. VETERAN'S NAME (Last, First, Middle Name)

16. SOCIAL SECURITY NUMBER

SECTION III - ELECTRONIC FUND TRANSFER INFORMATION
The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. Please attach a voided
personal check or deposit slip or provide the information requested below in Items 39, 40 and 41 to enroll in direct deposit. If you do not have a bank account, you
must receive your payment through Direct Express Debit MasterCard. To request a Direct Express Debit MasterCard you must apply at www.usdirectexpress.com
or by telephone at 1-800-333-1795. If you elect not to enroll, you must contact representatives handling waiver requests for the Department of Treasury at
1-888-224-2950. They will encourage your participation in EFT and address any questions or concerns you may have.
17. ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)
I certify that I do not have an account with a financial institution or
certified payment agent.

CHECKING:
SAVINGS:

18. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank where you

want your direct deposit to go)

19. ROUTING OR TRANSIT NUMBER (The first nine numbers

located at the bottom left of your check or savings deposit slip)

SECTION IV - ADOPTION INFORMATION
20. NAME OF ADOPTED CHILD (Last, First, Middle Name)
23. DATE OF HOME STUDY

22. GENDER
MALE

FEMALE

(mm/dd/yyyy)

26. STATE OR COUNTRY WHERE ADOPTION WAS FINALIZED

21. DATE OF BIRTH (mm/dd/yyyy)
24. DATE CHILD PLACED IN HOME

(mm/dd/yyyy)

25. DATE ADOPTION FINALIZED

(mm/dd/yyyy)

27. ADOPTION ARRANGED BY (Documentation attached) (Check one)

a. A state or local governmental agency.
b. A nonprofit adoption agency that is authorized by state or local law to
place children for adoption.
c. Other source authorized by state or local law to place children for adoption.
d. A foreign government or an agency authorized by a foreign government
to place children for adoption (See instructions).

NOTES:
1. Reimbursement of adoption expenses may be paid only after the adoption is final after September 29, 2016, and in the case of foreign adoptions, after U.S.
citizenship has been granted.
2. Reimbursement claims must be submitted no later than 2 years after the adoption is finalized, or in the case of a foreign adoption, 2 years after U.S. citizenship is
granted.

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28. EXPENSES INCURRED (Complete as applicable and attach documentation)

a. Public and private agency fees.
b. Placement fees, including fees charged adoptive parents for counseling.
c. Legal fees, including court costs.
d. Medical expenses, including hospital expenses of the biological mother and newborn infant, for medical care furnished the adoptive
child before the adoption, and for physical examinations of the biological mother of the child to be adopted.
e. Temporary foster care charges when such care is required before placement of the child.
f. Subtotal of expenses listed above (Items 28.a. through 28.e.)
g. Amount of reimbursement previously applied for and/or received under any other adoption benefits program administered by the
Federal government or under such program administered by a State or Local government.
h. Total expenses (Subtotal (Item 28.f.) minus any reimbursements in Item 28.g.)

SECTION V - AFFIRMATION
I affirm that the above information and expenses are true and correct to the best of my knowledge. I understand and agree that reimbursement of qualifying adoption
expenses is limited to $2,000.00 per adopted child with maximum reimbursement of $5,000.00 in any calendar year to a covered veteran, or couple where both
spouses are covered veterans. I understand that I am allowed to submit only one reimbursement claim per adoption.
I further affirm that neither I nor my spouse have received a reimbursement under any other adoption benefit program administered by the Federal government or
any state or local government. To the best of my knowledge I am the only covered veteran claiming reimbursement for the named adopted child.
29. VETERAN’S NAME (Last, First, Middle Initial)

a. VETERAN’S SIGNATURE (Sign in ink)

b. DATE SIGNED (mm/dd/yyyy)

PRIVACY ACT NOTICE AND PAPERWORK REDUCTION ACT
PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy
Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological
or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA
programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records. Your obligation to
respond is voluntary; however, no reimbursement may be granted unless this form is completed fully as required by law. Providing the applicant’s or spouse’s
Social Security numbers is mandatory. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by
a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum
benefits under the law.
RESPONDENT BURDEN: VA is asking you to provide the information on this form under Public Law 114-223 section 260 and 38 CFR 17.390 in order for VA
to determine your eligibility for reimbursement of qualifying adoption expenses (38 U.S.C. 5101). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 6 hours to review the instructions, find the information, and complete this form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is
not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

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APPLICATION PPROCESSING INSTRUCTIONS
1. This form must be completed in its entirety and affirmed by the veteran.
2. The veteran will provide documentations supporting placement by an authorized source, any final court papers including
translations if necessary, all substantiating receipts in U.S. currency amounts with the claim, and in the case of foreign adoptions,
submit proof of U.S. citizenship for the adopted child.
3. The veteran must retain copies of all paperwork until the claim is paid or denied.
4. The completed form and claim application package, with original signature of the veteran, must be submitted.
5. If the adoption and expenses are eligible for reimbursement, VA will approve and certify payment. Reimbursement will be by
Electronic Fund Transfer (EFT) to the applicant’s EFT account.
6. If eligibility for reimbursement cannot be determined from the documents provided or claimed expenses are not properly supported
by receipts, VA will retain the claim and request the necessary information or documentation. The additional information or
documentation must be submitted within 90 days for the claim to be considered.
7. If the claim is denied, VA will notify the applicant in writing.

Purpose:

This form may be used by a covered veteran to request reimbursement of qualifying adoption expenses. A covered veteran may
request reimbursement for qualifying adoption expenses incurred by the veteran in the adoption of a child under 18 years of age.
1. An adoption for which expenses may be reimbursed includes an adoption by a married or single person, an infant adoption, an
intercountry adoption, and an adoption of a child with special needs (as defined in section 473(c) of the Social Security Act (42
U.S.C. 673(c)).
2. Reimbursement for qualifying adoption expenses may be requested only for an adoption that became final after September 29, 2016.
3. In the case of adoption of a foreign child, reimbursement for qualifying adoption expenses may be requested only after United
States citizenship has been granted to the adopted child.
4. Reimbursement for qualifying adoption expenses may not be paid for any expense paid to or for a covered veteran under any other
adoption benefits program administered by the Federal Government or under any such program administered by a State or local
government.

How To Submit:
Send your application and any evidence in support of your claim to the following address:
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
Applying for additional allowance for dependents.
You can apply for an additional allowance and/or remove of dependent(s) online through eBenefits at
www.ebenefits.va.gov. To file a claim for dependents electronically, go to eBenefits, select Apply for Benefits and then
Apply for Add or Remove Dependent. You will need to create an eBenefits account to apply for dependents online. Once
you submit your claim, you can track the status using eBenefits. NOTE: You can contact an accredited Veteran Service
Officer to assist you with your electronic application.
Who is a “covered veteran” ?

“Covered veteran” means a veteran with a service-connected disability that results in the inability of the veteran to procreate without
the use of fertility treatment.

What is a “qualifying adoption expense”?

“Qualifying adoption expenses” means reasonable and necessary expenses that are directly related to the legal adoption of a child
under 18 years of age, but only if such adoption is arranged by a qualified adoption agency or other source authorized to place
children for adoption under State, foreign or local law. Such term does not include any expense incurred:
1. for incidentals such as clothing, bedding, and books;
2. by an adopting parent for travel; or
3. in connection with an adoption arranged in violation of Federal, State, or
local law.

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What does “reasonable and necessary expenses” mean?
“Reasonable and necessary expenses” includes:
1. public and private agency fees, including adoption fees charged by an agency in a foreign country;
2. placement fees, including fees charged adoptive parents for counseling;
3. legal fees (including court costs);
4. medical expenses, including hospital expenses of the biological mother of the child to be adopted and of a newborn
infant to be adopted; and
5. temporary foster care charges when payment of such charges is required before the adoptive child’s placement.

What is a “qualified adoption agency”?
“Qualified adoption agency” means any of the following:
1. A State or local government agency which has responsibility under State or local law for child placement through
adoption.
2. A nonprofit, voluntary adoption agency which is authorized by State or local law to place children for adoption.
3. Any other source authorized by a State to provide adoption placement if the adoption is supervised by a court under State or
local law.
4. A foreign government or an agency authorized by a foreign government to place children for adoption, in any case in
which:
a. the adopted child is entitled to automatic citizenship under section 320 of the Immigration and Nationality Act (8 U.S.C.
1431); or
b. a certificate of citizenship has been issued for such child under section 322 of that Act (8 U.S.C. 1433).

Filing deadlines:
Reimbursement for qualifying adoption expenses must be requested:
1. no later than 2 years after the adoption is final; or,
2. in the case of adoption of a foreign child, no later than 2 years from the date the certificate of United States citizenship is
issued.

Reimbursement limits:
1. Reimbursement per adopted child. No more than $2,000 may be reimbursed to a covered veteran, or to two such covered veterans
who are spouses of each other, for expenses incurred in the adoption of a child.
2. Maximum reimbursement in any calendar year. No more than $5,000 may be paid to a covered veteran, or to two such covered
veterans who are spouses of each other, for adoptions by such veteran (or veterans) in any calendar year.

Authority:
Authority to provide reimbursement for qualifying adoption expenses incurred by the veteran in the adoption of a child under 18 years
of age expires September 30, 2018.

Required documentation:
A copy (not original) of the following documents must be submitted with the application to establish eligibility for reimbursement of
qualifying adoption expenses.
NOTE: The covered veteran must submit a full English translation of any foreign language document, to include the translator’s
certification that he or she is competent to translate the foreign language to English and that his or her translation is complete and
correct.

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To establish:
1. That you are a covered veteran for U.S. adoptions and adoption of a foreign child:
A VA determination that you are a veteran with a service-connected disability that results in the inability of the veteran to procreate
without the use of fertility treatment.

2. That the adoption is final for:
U.S. adoptions: A copy of the final adoption decree, certificate or court order granting the adoption. For U.S. adoptions, the court
order must be signed by a judge unless either State law or local court rules provide that the adoption order may be signed by a
commissioner, magistrate or court referee.
Adoption of a foreign child: For foreign adoptions, a court order or other instrument signed by a judge or other official authorized
under the laws of the foreign country to issue such order or instrument.

3. Proof of citizenship:
For foreign adoptions or adoption of a foreign child, proof of U.S. citizenship of the child, including any of the following:
(i) A copy of Certificate of Citizenship.
(ii) A copy of a U.S. court order that recognizes the foreign adoption, or documents the “re-adopting” of the child in the
United States.
(iii) A letter from the United States Citizenship and Immigration Services, which states the status of the child’s adoption.
(iv) A copy of U.S. passport (page with personal information only).

4. That the adoption was handled by a qualified adoption agency:
For U.S. adoptions: You must have documentation to show that the adoption was handled by a qualified adoption agency or other
source authorized by a State or local law to provide adoption placement.
Other acceptable forms of proof that the adoption was handled by a qualified adoption agency include:
(i)

A copy of placement agreement from the adoption agency showing the agreement entered into between the member and the
agency.
(ii) A letter from the adoption agency stating that the agency arranged the adoption and that the agency is a licensed child placing
agency in the United States.
(iii) Receipts for payment to the adoption agency, as well as proof, (e.g., a copy of the agency’s web page), of the agency’s status
as a for-profit or non-profit licensed child placing agency.
For foreign adoptions: You must have documentation that the adoption was handled by a qualified agency and must include a
document that describes the mission of the foreign agency and its authority from the foreign government to place children for
adoption; and placement agreement from the adoption agency or letter from adoption agency stating the specific services it
provided for the adoption.
Other acceptable forms of proof that the adoption was handled by a qualified adoption agency include:
(i)

A copy of placement agreement from the adoption agency showing the agreement entered into between the member and the
agency.
(ii) A letter from the adoption agency stating that the agency arranged the adoption and that the agency is a licensed child placing
agency in the United States.
(iii) Receipts for payment to the adoption agency, as well as proof, (e.g., a copy of the agency’s web page), of the agency’s status
as a for-profit or non-profit licensed child placing agency.

5. Reasonable and necessary expenses paid by the covered veteran:
Acceptable forms of documentation include receipts, cancelled checks, or a letter from the adoption agency showing the amount
paid by the member. Receipts from a foreign entity should include the U.S. currency equivalency. Reconstruction of expense
records is permissible when the original records are unavailable and the covered veteran submits a notarized affidavit stating the
costs.

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