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  • Dependent Care Receipt

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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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Dependent care FSA receipt requirements Dependent Care FSAs are designed to help employees pay for childcare, eldercare, or other dependent care expenses. These pre-tax funds should be used to arrange for appropriate care of dependants while the employee is at work.

What information should be provided in the Childcare receipt form? Name, address and telephone number of the provider. Name, address and phone number of the parent. Amount of childcare hours. Description of the events. Price for one hour. Total cost of the child care.

Daycare. Babysitting. Nursery school, preschool (not private school, summer school, or tutoring) Sick child care.

Once you have paid for expenses that qualify for reimbursement from the FSA, you will need to complete a claim form provided by your employer and attach receipts or proof of payment with the form. The receipts must include specific information to prove that the payment was for qualified expenses.

You will need an Itemized Receipt from the day care provider. The receipt must reference the from/through date of service and be signed by the provider (or on the provider's letterhead).

You will need an Itemized Receipt from the day care provider. The receipt must reference the from/through date of service and be signed by the provider (or on the provider's letterhead).

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232