Free FSA Daycare Receipt Outline Template
FSA Daycare Receipt Outline
[YOUR COMPANY NAME] | [YOUR COMPANY ADDRESS]
Parent/Guardian Name: [PARENT/GUARDIAN NAME]
Child Name: [CHILD NAME]
Service Dates: [START DATE] – [END DATE]
|
Description |
Amount |
|---|---|
|
Total Days of Care |
[NUMBER OF DAYS] |
|
Cost per Day |
$[AMOUNT] |
|
Total Amount Paid |
$[TOTAL AMOUNT] |
Payment Method: [CASH/CHECK/OTHER]
Date of Payment: [PAYMENT DATE]
Signature (Provider): [SIGNATURE]
Date: [DATE SIGNED]
