Daycare Receipt for FSA Reimbursement Template
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Daycare Receipt for FSA Reimbursement
Provider Name: [YOUR COMPANY NAME]
Provider Address: [YOUR COMPANY ADDRESS]
Child's Name: Jasen Gaylord
Dates of Service: 01/01/2065 - 01/31/2065
Receipt Date: 01/31/2065
Payment Breakdown:
Description | Amount |
|---|---|
Weekly Care Fee | $400.00 |
Extra Hours | $50.00 |
Total Paid | $450.00 |
Payment Method: Credit Card
Authorized Signature: [SIGNATURE]
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