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Get and Sign Medical & Dependent Daycare Reimbursement CLAIM FORM 2015-2022
Service We re sorry but Credit Card Receipts or Cancelled Checks are not acceptable by the IRS. Date of Service Name of Provider Amount Offset OFFSET NOTE Enter Y or N to offset an existing debit card transaction with this expense. To reactivate debit card Total Unreimbursed Medical Expenses SECTION 3 DEPENDENT DAYCARE EXPENSES Attach Supporting Statement/Bill if Provider does not sign this form NOTE Qualified expenses include preschool expenses before school/after school care and regular...
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