Free Daycare Receipt for FSA Reimbursement Template
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]
