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5. Send completed form and attached documentation to gente. For Prompt Service Fax to 973-694-2913 or email claims gente. Solutions Dependent Care Provider Statement I provided the Day Care services as stated above. Day Care Provider Signature Tax ID Date I certify that the expenses listed above have been incurred by me and/or my dependent s and qualify for reimbursement and that these expenses will not be claimed as a deduction on my personal income tax return. Your Signature Rev 03/2016...

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