CHANCELLOR & CHANCELLOR, INC.

SECTION 125 PLAN

DEPENDENT CARE CLAIM FORM


Social Security No.: _________________________________________


Participant's Name: _____________________________________________________
                    Last                     First              Middle          


To: _______________________________________________________


        The undersigned participant in the plan requests reimbursement (attach 
        itemized bills, receipts and invoices for all expenses claimed) in the
        amounts shown below:


        1.      Name of Dependent(s) ______________________________________

        2.      Period Covered: From __________________________________ 19 ____

        Through _______________________________________________________ 19 ____

        3.      Name, address and, except for certain tax exempt organizations, 
                the taxpayer identification number of the service provider, and 
                description of service:


        _____________________________________________________________________

        _____________________________________________________________________

        _____________________________________________________________________

                                                        Amount $_____________


        NOTE: The total amount claimed under the plan for any coverage period 
        must not exceed the lesser of your wages or salary for the plan year
        or the wages or salary of your spouse. (If your spouse is either a full
        time student or is incapable of taking care of himself or herself then 
        he or she is deemed to have monthly earnings of $200 if there is one (1)
        child or dependent, and $400 if there are two (2) or more.) No payment
        may be made under the plan if the service provider is your dependent 
        for federal income tax purposes, or is your child or stepchild and is 
        under age 19.


READ CAREFULLY


The undersigned participant in the plan certifies that all expenses for which
reimbursement or payment is claimed by submission of this form, were incurred
during a period while the undersigned was covered under the Chancellor & 
Chancellor, Inc. Section 125 Plan with respect to such expenses. The 
undersigned fully understands that he or she alone is fully responsible for 
the sufficiency, accuracy and veracity of all information relating to this
claim which is provided by the undersigned, and that unless an expense for 
which payment or reimbursement is claimed is a proper expense under the Plan,
the undersigned may be liable for the payment of all related taxes including
federal, state or city income tax on amounts paid from the plan which relate
to such expense. The undersigned further understands that no dependent care 
tax credit is permitted for amounts for which reimbursement is made.


_______________________________________________         Date _____________
Employee's signature


For Plan Administrator use only                    For Employer use only

Payment Authorized ____________                    Check No. ___________

Amount $_______________________                    Date ________________


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