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Get Dependent Care Receipt

Instructions: This form may be used by a caregiver or provider of service as a receipt for qualified dependent care services provided. Be sure to provide all information requested by this form. If the form is incomplete, it will be returned to you. Print or type the information requested. Then date and sign the form. Send this form along with the Dependent Care Reimbursement Request Form to: MedBen, Specialty Services Unit, P. O. Box.

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