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Change Details
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Dependent Care Expense Details
| Household Member | [Full Name] | ||
|---|---|---|---|
| Care Recipient Name | [Full Name] | ||
| Care Provider | [Full Name] |
| Amount | Frequency | ||||||
|---|---|---|---|---|---|---|---|
| Start Date |
| End Date |
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| Reason | Last Payment Date |
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| Reimbursed Amount | Reimbursement Type | ||||||
| Total Hours Per Week |