Sample adoption assistance policy

Adoption Assistance Program

Adopting a child can be expensive. To help employees who choose to adopt, [Company Name] offers an adoption benefit to reimburse a portion of the expenses incurred.

Eligibility

All full-time employees in the United States and U.S. expatriates are eligible for this program. Part-time employees who are regularly scheduled to work at least 20 hours/week are eligible after 1 year of service. Temporary, seasonal and on-call employees are not eligible.

If both parents work for [Company Name], only one may file for the adoption benefit.

Eligible children. The child adopted must be under 18 years of age or physically or mentally incapable of caring for himself. The child may not be the child of the employee’s spouse.

How the Plan Works

When you begin adoption proceedings, keep a file of all your expenses. You do not need to wait until the adoption has been finalized (that is, when the adoption decree is signed and filed by the clerk of the court) to file for the adoption benefit. However, only two claims may be filed per adoption. There is a $25 minimum reimbursement.

The program pays 100 percent of all eligible expenses incurred while you are employed by [Company Name], up to a maximum of $5,000 per child. Should you adopt twins, you would be able to file for two benefits.

Eligible Expenses

The following charges related to the adoption are eligible for reimbursement from this program. If you have questions concerning an expense, contact Human Resources.

1. Legal fees.

2. Court fees.

3. Adoption agency fees, including foreign adoption fees.

4. Temporary foster care expenses.

5. Reasonable travel expenses (transportation, meals and lodging) while traveling away from home for the sole purpose of arranging for an adoption or to bring the child to the adopting parents.

6. Medical examination fees for the child, if required.

7. Eligible expenses incurred in connection with any unsuccessful attempt to adopt an eligible child before finalizing the adoption of another child.

Expenses not eligible. The following charges are not eligible for payment from this program.

1. Expenses for adopting your spouse’s child.

2. Medical examination fees for the adopting parents.

3. Cost of personal items such as clothing, food, etc. for either parents or child.

4. Expenses incurred while you are not a [Company Name] employee.

5. Expenses reimbursed under any other company program.

6. Expenses incurred in violation of state or federal law or in carrying out any surrogate parenting arrangements.

7. Pregnancy expenses for the birth mother.

Filing for Reimbursement

Follow this procedure to file reimbursement requests. You may only submit two request forms per child, per adoption.

1. Employee requests an Adoption Reimbursement Request form, available from Human Resources.

2. Employee completes the Adoption Reimbursement Request form and attaches:

   • Documentation stating the child(ren)'s placement date in the employee's home (copy of notarized or certified placement agreement); and

   • Copies of original receipts showing payment was made for all covered expenses.

3. Employee sends completed Adoption Reimbursement Request form and attachments to the address indicated on the form.

4. If request is approved, reimbursement payment will be processed within 6 weeks of receipt of the Adoption Reimbursement Request form (or, for employees on a leave of absence at that time, upon reinstatement to active regular employment). Reimbursement will coincide with the normal payroll cycle. If request is denied, in whole or in part, written notification will be sent to employee within 4 weeks of receipt of the Adoption Reimbursement Request form with reason(s) for denial.

No benefit will be paid unless the properly completed reimbursement form is filed within 12 months after the adoption is final. Please note that reimbursement will not be issued until the child(ren) is/are placed in the home.

If You Go on Leave. If you take an approved leave, you can file for adoption reimbursement once you have returned to work as a regular full-time or part-time employee, but only if the form is filed within 12 months after the adoption is final.

If You Are Disabled. If you are on an approved short-term disability leave when the adoption is final, you can apply for reimbursement under this program as if you were an active employee.

If You End Employment. If your employment with [Company Name] ends for any reason (including retirement) before the adoption is finalized, you are no longer eligible for this benefit, even if the adoption was started before you left the company.

If You Die. If you have started adoption proceedings and die while eligible for this benefit, the adoption expenses are eligible for reimbursement if the adoption is finalized within 12 months after your death. Your surviving spouse must be the other adopting parent and must file the reimbursement form within 12 months after the adoption is final.

Taxation of Benefits

Benefits paid under the program may be excludable from your federal taxable income. In general, reimbursements for qualifying adoption expenses you incur on or after January 1, 2001 may be excluded, subject to certain income limitations. All reimbursements, whether or not excludable from your income, will be added to your W-2 earnings statement. To ensure optimum tax savings, always consult your tax professional to determine the proper treatment of the reimbursements.

Other Benefits. Once you have custody of the child, even though the adoption is not final, you may be able to cover the child under your medical, dental, and life insurance benefit plans. You must enroll for this coverage within 31 days of obtaining the child. The eligibility requirements for each plan are further defined in the appropriate Summary Plan Description.

Plan Life

[Company Name] intends to continue the program indefinitely. Because it is impossible to know what will happen in the future, the company does reserve the right to change or discontinue the program at its sole discretion.