Adoption/SurrogacyExpenses Reimbursement Form

All eligible Crewmembersmay submit a request for financial support to help defray expenses related tocosts associated with adoption or surrogacy up to a lifetime maximum of $10,000. Qualifiedadoption or surrogacy expenses includeadoption agency fees, court costs, attorneys’ fees, and other expenses directly related to, and whose principal purpose is for, the legal adoption or birth through surrogacy of an eligible child. An eligible child must be under age 18 years and not related to the Crewmember.

Please complete this form and return to BlueBenefits, along with any itemized bills, receipts, and proof of payment for each expense listed below as well as documentation demonstrating that a legal adoption has been finalized or the child was born as a result of a surrogacy arrangement.

Once approved, the reimbursement amount will be included your paycheck within two pay cycles. Applicable taxes associated with surrogacy expenses will be deducted in accordance with IRS regulations. Applications must be submitted no later than 90 days after the finalized adoption/surrogacy of an eligible child. For a full description of this benefit, please refer to the Adoption Assistance Program policy for details.

There are several steps you may need to take in relation to your benefits when you become a new parent. If you are a medical, dental or vision plan participant, you may wish to modify your coverage to include your child. For details on how to make your changes, please visit to request a Qualified Life Event. All steps and enrollment must be completed within 90 days of the event.

Crewmember Request for Reimbursement

Crewmember Name
Crewmember ID
Work Location
Workgroup
Phone
Email
Child Name
Child Date of Birth
Date of Adoption

Eligible Adoption/SurrogacyExpenses:

Date of Expense / Provider / Description of Expense / Amount
$
$
$
$
$
$
$
$
$
$
$
$
$
Total Adoption Expenses / $
Total Surrogacy Expenses / $
Total Reimbursement / $

I certify that the receipts and proof of payment I am submitting are qualified adoption expenses under the JetBlue Adoption Assistance Program. I also certify that these eligible expenses are in accordance with the JetBlue Adoption Assistance Program and have not been nor will they be reimbursed under any other program or source. I further acknowledge that any applicable taxes related to eligible surrogacy expenses will be deducted from my reimbursement payment.

______

Crewmember SignatureDate

BLUEBENEFITS USE ONLY:
Approved & Reimbursement Amount: $______
Denied & Reason: ______
BlueBenefitsSignature: ______ / Date:______