Name: / EMPLOYEE #:
**Your employee # can be found on the top right corner of your pay stub
Region#: Division#: Home Office
Department#: National Store#:
Job Information / CSD: / Work Telephone#: ( ) - / Dept. 148-G/L Account #8017-001
Adoption Information / I wish to apply for reimbursement for the Last First Middle
following expenses related to the adoption of:
date This child was placed in my home:
Eligible expenses must fall into one of the categories below. No reimbursement will be made for donations, legal guardianship expenses or expenses when either adopting parent is a relative of the adopted minor child.
Type of Expense / Expenses paid to / Date / Amount Paid
Adoption/Placement Fees
Legal/Court Fees
Uninsured Maternity Expenses for the birth mother
Reasonable Transportation Expenses for Adopting Parents
Immigration Fees for the Adopted Child
Total
Attach proof of payment for the items listed above along with a copy of the adoption papers or final placement agreement. Adoption assistance reimbursement may be excludable from gross income for federal, state and local income tax purposes.
Signature / I hereby certify that above information is correct and my newly adopted child was placed in my home on the date indicated above.If I terminate my employment for any reason or change to an ineligible class within six months of the date the child is placed in my home I agree to reimburse the Company for the Adoption benefits paid to me. In addition, any payments made to me in excess of the McDonald’s Adoption Assistance Benefit will be reimbursed by me to McDonald’s. In either case, I authorize the Company to make such deductions from any money payable to me.
Employee Signature: / Date:
Please forward this completed form and all required attachments (if applicable) to: FORM 3842 02/15/07
McDonald’s Service Center Dept. 238, McDonald’s Corporation, 2111 McDonald’s Drive, Oak Brook, IL, 60523
Telephone #: (877) 623-1955 Fax #: (630) 623-5027 E-mail address: