Reimbursement Form

Keys to Independence Reimbursement Request ( v1.2 )

Note: To expedite payment, we encourage our youth, caregivers and service providers to receive reimbursement via direct deposit. Click Here to apply for direct deposit.

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.

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.
Please indicate months for which you are requesting insurance reimbursement. (Check all that apply.)

Make Check Payable To

Name(Required)
Address(Required)

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

Please upload all receipts and supporting documentation for the reimbursement request.
Drop files here or
Max. file size: 100 MB.