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R have the provider sign this form) and the taxpayer ID Number from each person providing care. List each dependent receiving care on a separate line. List each provider on a separate line. Attach the appropriate documentation information. NAME Employee ID NUMBER ADDRESS (STREET) EMPLOYER 99UNIVERSITY OF VERMONT ADDRESS (CITY, STATE, ZIP CODE) DEPENDENTS FULL NAME AGE RELATIONSHIP DATES OF CARE: FROM TO NAME OF CARE PROVIDER AMOUNT (ATTACH PROOF OF EXPENSE) DATES OF CARE: FROM TO NA.

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