Dependent Care Receipt
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1DEPENDENT CARE RECEIPT
Please Print
Received from
(Parent's Name)
payment for dependent care services for the period
to
in the amount of $
.
Name of Facility or Person Providing Care
Signature of Provider
Date
*** All Receipts must be attached to a Dependent Care Reimbursement Request Form ***
======================================================
DEPENDENT CARE RECEIPT
Please Print
Received from
(Parent's Name)
payment for dependent care services for the period
to
in the amount of $
.
Name of Facility or Person Providing Care
Signature of Provider
Date
*** All Receipts must be attached to a Dependent Care Reimbursement Request Form ***
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