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Ployer: Employee Name: Social Security Number: Phone: E-mail: Dependent Care Expense Claims Name & Date of Birth of Dependent(s) Period Covered From To Attach a receipt from your daycare provider, or include the daycare provider's signature. Name, Address, and Taxpayer Identification Number (or SSN) of Service Provider Amount Incurred Provider's Signature: Total Dependent Care Expense Claim* $ *NOTE: The total amount claimed under the Plan for any coverage period must not exceed.

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