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Get Flex-Pay Reimbursement Claim form

Ee Name: Phone: Social Security: E-mail: DEPENDENT CARE EXPENSE CLAIMS Name of Dependents Period Covered From To Name, Address & Tax Identification Number of Service Provider Total Dependent Care Expense Claim* ï Amount Incurred $ Attach receipt(s) from your daycare provider to the left, Address Change:________________________________________ or if none available, have the provider sign below ______________________________________________________ _____________________________________.

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