Has Paid $ ___________ for childcare expenses for the month of ______________________
Name of Provider: _______________________________________________
Social Security Number or Tax I.D. #: ________________________________
Address: _______________________________________________________
City: __________________________ State: ________ Zip: ________________
Signature __________________________________________
(Child Care Provider)
EMPLOYEE CERTIFICATION FOR REIMBURSEMENT
I
certify that the expenses for reimbursement requested from my account was
incurred by me (and/or my spouse and/or eligible dependent), were not reimbursed by any other plan, and, to the best of my knowledge and belief, are
eligible for reimbursement under my Reimbursement Plan. I (or we)
will not use the expense reimbursed through this account as deductions or
credits when filing my (our) individual income tax return.
Employee Signature: _____________________________________________
Employer: _____________________________________________________