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Cafeteria Plan
Dependent
Daycare Receipt
Parent’s Nam
e______________________________________________
Child’s Name
Age
DATE OF SERVICE
From
:
To
:
FEE
for Service
1
$
2 $
3 $
4
$
5
$
Total: $
Name of Dependent Adult or C
hild
over 13 with q
ualifying restrictions
DATE OF SERVICE
From
:
To
:
FEE
for Service
1
$
Provider Information
Provider’s Name:
Address
City State Zip
Telephone Number:
Tax ID/SSN:
Daycare Provider Date
Notice to Cafeteria Plan Participant:
No payment may be made under the plan if the service
provider is your dependent for federal income tax purpose, or is your child or stepchild and is under
age 19. The dependent you are claiming must be under age 13 or have qualifying restrictions.
ATTA
CH THIS RECEIPT TO
A
COMPLETED CAFETERIA PLAN CLAIM FORM
©Ben
-
X, LLC 2008
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Email: [email protected]
FAX: (801) 224-1903
Website: www.MyBenX.com
Ben-X, LLC
Rev 10.01
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