Cafeteria Plan Dependent Day Care Receipt
ADVERTISEMENT
1CAFETERIA PLAN
DEPENDENT DAY CARE RECEIPT
PARENT’S NAME:
CHILD’S NAME:
AGE:
DATE OF SERVICE: FROM
TO
FEE FOR SERVICE:
$
AMOUNT RECEIVED:
$
CARE PROVIDED BY:
NAME:
ADDRESS:
TELEPHONE:
SOCIAL SEC# OR BUSINESS ID#
PROVIDER 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 DEPENDENT CARE CLAIM
FORM
CAFETERIA PLAN
DEPENDENT DAY CARE RECEIPT
PARENT’S NAME:
CHILD’S NAME:
AGE:
DATE OF SERVICE: FROM
TO
FEE FOR SERVICE:
$
AMOUNT RECEIVED:
$
CARE PROVIDED BY:
NAME:
ADDRESS:
TELEPHONE:
SOCIAL SEC# OR BUSINESS ID#
PROVIDER 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.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business