Dependent Day Care Receipt
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1Dependent Day Care Receipt
Received from:_____________________________ Amount:_____________________
Description of Day
Name(s) of dependent(s)
Care Services:_____________________
receiving care:_________________________
Dates of Service:________________________________________________________________________
Are you, the Day Care Provider, related to the participant? Circle one
Yes
No
If Yes, describe:________________________________________________________________________
Signature of day care provider:_____________________________________________________________
Day Care Provider’s tax ID # or SS #:_______________________________________________________
Dependent Day Care Receipt
Received from:_____________________________ Amount:_____________________
Description of Day
Name(s) of dependent(s)
Care Services:_____________________
receiving care:________________________
Dates of Service:_______________________________________________________________________
Are you, the Day Care Provider, related to the participant? Circle one
Yes
No
If Yes, describe:________________________________________________________________________
Signature of day care provider:____________________________________________________________
Day Care Provider’s tax ID # or SS #:______________________________________________________
Dependent Day Care Receipt
Received from:_____________________________ Amount:_____________________
Description of Day
Name(s) of dependent(s)
Care Services:_____________________
receiving care:________________________
Dates of Service:_______________________________________________________________________
Are you, the Day Care Provider, related to the participant? Circle one
Yes
No
Signature of day care provider:____________________________________________________________
Day Care Provider’s tax ID # or SS #:_______________________________________________________
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Parent category: Business