Dependent Daycare Receipt

Download a blank fillable Dependent Daycare Receipt in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Dependent Daycare Receipt with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

3125 Airport Parkway, Cambridge, MN 55008
Metro: 763-552-6053 Toll Free: 888-507-6053
Fax: 763-552-6055
A division of Educators Financial Services, Inc.
Section 125 Flexible Benefits Plan - Dependent Daycare Receipt
Parent’s Name: ___________________________________________
Child’s Name
Age
Date of Service: From __________________to _________________
Fee for Service: $_________________________________________
Provider’s Name: ___________________________________
Address: ________________________________________
_________________________________________
Telephone Number: _________________________________
Tax ID/SSN: ______________________________________
Provider’s Signature: _______________________________________
• Notice to Cafeteria Plan Participant: No payment may be made under the plan if the service
provider is your dependent for federal income tax purpose, or is your child or stepchild and
is under age 19. The dependent you are claiming must be under age 13 or have qualifying
restrictions.
THIS FORM MUST BE SUBMITTED ALONG WITH A REIMBURSEMENT CLAIM FORM.
EBC DCRCPT 03/05

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go