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I also certify the care provider is not my dependent my child under the age of 19 or my spouse. Employee Signature Date. CLEAR FORM Financial Services and Operations Third Floor Lakeshore Center 1400 Townsend Drive Houghton MI 49931-1295 906/487-2242 Michigan Technological University Dependent Care Reimbursement Form result from university business travel will be reimbursed up to a maximum of 300/day/trip. This form must be completed and attached to a travel expense form with original...
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