Reimbursement Form

Keys to Independence Reimbursement Request ( v1.2 )

With our recent transition to FLITE Center, we are now ONLY offering direct deposits (ACH). You will find our ACH form and W9 HERE. Please follow the instructions closely and submit all documents requested. You will only need to submit this one time unless your banking information changes.

Complete this form and upload all required documentation. All reimbursement requests must be accompanied by documentation indicating payment receipt and, when applicable, completion of the service (i.e., completion of a driver’s education course).

Reimbursement of an approved expense will be made within thirty days of receipt of the request. Program staff will contact the youth and his/her caregiver if any further documentation is required or if a reimbursement cannot be made. Reimbursements and payments for services will be made as funding is available.

If you are requesting reimbursement for insurance, please note the following eligibility requirements, per Florida statute:

  • Youth completed behind the wheel lessons/driver’s education
  • Youth holds an active driver’s license
  • Youth is actively enrolled in K2I

Youth Information

Name(Required)
Address

Caregiver Information

Name(Required)
Address

Expense Reimbursement

Note: Unless otherwise specified, the actual cost of each expense may be reimbursed. Must attach receipt for any of the expense reimbursement items requested below.

I Hereby Certify That

Consent(Required)
Please type your name below. By typing your name in this field, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By typing your name in this field, you consent to be bound the policies and procedures of the Keys to Independence program.*
Please type your name below. By typing your name in this field, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By typing your name in this field, you consent to be bound the policies and procedures of the Keys to Independence program.

Supporting Documentation

Required documents include:

  • Receipts for all listed expenses needing reimbursement.
  • Permit or License fee – include picture of the permit or license.
  • Completed ACH form.
  • If a partner agency or business, completed W9.
  • Insurance reimbursement - include the declaration page with the youth’s name clearly visible on the policy.
  • Driver’s education or lessons - include certificate of completion.
Drop files here or
Max. file size: 100 MB.
    BEFORE YOU SUBMIT, PLEASE ENSURE THAT YOU HAVE UPLOADED ALL REQUIRED DOCUMENTATION FOR THIS REIMBURSEMENT REQUEST. IF YOU HAVE NOT, THE REQUEST WILL BE RETURNED TO YOU AND YOU WILL BE REQUIRED TO RESUBMIT WITH THE REQUIRED DOCUMENTATION.