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Get Dependent Care Receipt

Number or Business ID Number Provider Street Address, City, State, Zip Code Date of Service From: Provider Signature Provider Phone Number Fee For Service To: Amount Received $ $ Employee Signature Date 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.

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