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Reimbursement for Child Care Form <br /> <br />Complete the information below. Obtain the child care <br />provider's signature (below) and mail this to: <br /> <br />Out for Lunch <br />Box 7605 Ricks Hall <br />North Carolina State <br />University <br />Raleigh, NC 27695-7605 <br /> <br />County: <br />Paid to <br /> <br />Date: <br /> <br />For child care services <br />for <br /> <br />For the amount of <br /> <br />Reimbursement to be paid to <br /> <br />Mailed to <br /> <br />(time period of services) <br /> <br />Signature of Child Care Provider <br />(Recipient of Payment) <br /> <br />Form 1 4 <br /> <br /> <br />