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.: ( ) Tax Payment Instructions: Month / Day Year (required by the Internal Revenue Revenue Service): Date, Place of Birth: If the total of all charges exceeds $500 this amount is deducted from this total and deducted from all refunds. Date, Place of Birth: If I do not remember the total of all the child care fees paid for the period, please provide a separate statement. Amount of Child Care Expenses to These child care fees were paid for the period of Month/Day I received from: the sum of $ Name of parent of parents (or other person, if applicable) for paying for: First and last name of Child or Children to These child care fees were paid for the period of Month/Day Information about the person or company issuing this receipt/affidavit. Month/Day Year (required by the Internal Revenue Service): Child Care Provider's Printed Name: Address: Telephone No.: ( ) Provider Tax Identification No.: ( ) Tax Payment Instructions: Month / Day Year (required by the Internal Revenue Revenue Service): Child Care Provider's Printed Name: Address: Telephone No.: ( ) Provider Tax Identification No.: ( ) Child Care Provider's Address: Child Care Provider's Telephone (required by the Internal Revenue Service): Date, Place of Birth: If the total of all Child Care Expenses has exceeded this amount this amount is deducted from this total and deducted from all refunds. (required by the Internal Revenue Service): If the total of all Child Care Expenses has exceeded this amount this amount is deducted from this total and deducted from all refunds. Month/Day Year (required by the Internal Revenue Revenue Service): Date,Place of Birth: The child care fees I received from: The total of all Child Care Expenses was between $500 and $1,000 for the relevant period and I have received a report on this. Child Care Provider's Print Name: Child Care Provider's Street Address: If the parent of the child was a corporation or other business entity, the name and address (or address of a principal office) of its registered agent for service of process shall be provided in this report. If the parent of the child was a corporation or other business entity, the name and address (or address of a principal office) of its registered agent for service of process shall be provided in this report. Date,