Surrogacy Agency Expense Reimbursement Form

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Name of Surrogacy Agency Submitting Request*

Please provide 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 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. 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.

To Whom Are We Making Payment?*

The Agency

The Gestational Surrogate

A Third Party

Name of the Person or Party Receiving the Payment

Please provide the name of the 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).

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

Max. file size: 100 MB.

Comments

Please include any information you would like to add to assist us in processing this request.

Name of Person Completing Form*

Please enter your name.

Email Address of Person Completing Form*

Please provide an email address where we may contact you with questions.

Enter Email Confirm Email

Gestational Surrogate's Email Address*

Please provide the gestational surrogate's email address if you would like us to confirm with the donor that payment has been sent to her.

Additional Email Address

Please include any emails to be cc'd on this request.

Surrogacy Agency Expense Reimbursement Form

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