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Surrogacy Agency Expense Reimbursement Request
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Surrogacy Agency Expense Reimbursement Request Form
Name of Surrogacy Agency Submitting Request
*
Please include the name of the surrogacy agency submitting a request for reimbursement or request for payment. Please note this form is for surrogacy expenses only. Egg Donation expenses should be submitted using the Donor Agency Expense Reimbursement Form.
Name of Person Submitting Request
*
Please identify the name of the person at the agency who is submitting the request.
Name of Escrow Account
*
Please provide the name of the intended parents or the name of the gestational surrogate from whose account Stork Escrow will be remitting payment.
Name of Gestational Surrogate
Please provide the name of the gestational surrogate for whom payment is being made. Please note this field is OPTIONAL.
Surrogacy Expense Being Paid
*
Please select the type of surrogacy expense for which you seek payment or reimbursement. You may select as many categories as needed. Please attach receipts, invoices or your agency form below and provide any additional description in the comment section below that may help us process the payment. If you would like a payment to be calendared for automatic monthly distribution, please note this in the comment section below. For Per Diem reimbursements please remember to complete the fields specific to payments of a Per Diem below. For Lost Wages please provide additional details in the comment section below or instead complete the Surrogate Lost Wage Reimbursement Form.
Agency Fee
Replenish Agency's Expense Account
Medical or Laboratory Bill
Life Insurance Premium
Health Insurance Premium
Psychological Evaluation
Legal Fees
Travel-related Expenses (taxi, Uber/Lyft, mileage, gas, parking, tolls etc.)
Per Diem
Childcare Expense
Housekeeping Expense
Prescription or Miscellaneous Pharmacy/OTC Expense
Surrogate Monthly Allowance
Compensation to Surrogate for Med Start
Compensation to Surrogate for Mock Cycle
Compensation to Surrogate for Dropped/Cancelled Cycle
Compensation to Surrogate for Embryo Transfer
Compensation to Surrogate for Confirmation of Pregnancy (positive beta)
Compensation to Surrogate for Confirmation of Pregnancy (confirmation of HB by ultrasound)
Compensation to Surrogate for Delivery
Compensation to Surrogate for C-Section
Compensation to Surrogate for Invasive Procedure
Pumping Compensation or Pumping-Related Expenses
Lost Wages
Close Escrow Account
Other not listed
To Whom Are We Making Payment?
*
Please let us know whether we are paying the agency, or provide the name of person or third-party to whom we are sending payment. If you are requesting payment to multiple individuals, please list each name separated by an "&" and provide any additional details in the comment section below so that the correct payment is sent to each individual (unless you are attaching an agency form which details the individual payments).
Total Amount to be Paid or Reimbursed
*
In addition to attaching any agency forms which detail the amount to be paid, please provide the total amount needed to be paid in connection with your request. You do not need to include a dollar sign ($), please input the number only (6000.00).
Gestational Surrogate's Email Address
If you would like us to inform the gestational surrogate that payment has been sent, please provide her email address. Otherwise, confirmation that payment has been sent will only be sent to the agency.
Comments
Please include any information you would like to add to assist us in processing this request.
Please attach any receipts, invoices, or agency forms here.
Please remember to attach any receipts, forms, paystubs, invoices, or other forms here (including any agency generated reimbursement forms).
Drop files here or
Email Address of person submitting form.
*
Additional Email Address
Please include any emails to be cc'd on this request.
Form Consent
*
I understand that by submitting this form I give consent to Stork Escrow to collect my personal information in accordance with their privacy policy and to contact me and any additional people I have included above at the email address(es) I have listed.
I agree to the Stork Escrow privacy policy.
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Comments
This field is for validation purposes and should be left unchanged.
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EMAIL:
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