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Confirmation

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Released to Authorizer

You have successfully released this EAV to the Authorizer on .
Your confirmation number is: 12345

05/01/2014 - 05/31/2014 EAV BACKDATED
For Care Provider: ABC Childcare, 123456789, 123   1111 Main St., Suite 111, Nashville, TN 37219

Please print this page for your records. Contact Fiscal Services at 1-800-362-8004 for any questions about payment.

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Child Name SSN 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Sample, Kate A xxx-xx-1111 5 1 2 8 8     8 8 8 8 A     8 4 4 8 8     H 4 4 4 4     A A C
Test, Jimmy J xxx-xx-2222 4 7 8 8 8     5 8 8 8 8     8 8 8 8 8     5 5 8 5 8     8 8 C
Test, Joey A xxx-xx-3333 4 7 8 8 8     5 8 8 8 8     8 8 8 8 8     8 8 8 8 8     A 8 C

Children Added This EAV Period

Child Name SSN 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Demo, Jane M xxx-xx-4444 5 1 2 8 8     8 8 8 8 A     8 4 4                            

Additional Comments
(Include notes or comments about child absences or exceptions to schedules if necessary)

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