The 125Company, Inc.
Day Care Provider Receipt
Employee Name:
Social Security Number
Day Care Provider’s or Facility Name:_______________________________________________
Providers EID# or SS#:___________________________________________________________
Providers Address:_______________________________________________________________
City:___________________________ State:______________________ Zip Code:___________
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Day Care Services Provide For:
Name:
Age:________
•
Date Services Incurred:
From:
To:
Amount Paid: $
Name:
Age:________
•
Date Services Incurred:
From:
To:
Amount Paid: $
Name:
Age:________
•
Date Services Incurred:
From:
To:
Amount Paid: $
Name:
Age:________
•
Date Services Incurred:
From:
To:
Amount Paid: $
•
Day Care Provider’s Signature:
Date: