Parent(s) 2019 Medical/Dental Expense Form (inactive)
Student/Parent Information
CMC Student Name
CMC Student Name
*
First
Middle
Last
CMC Student ID Number
*
Must be
8
digits.
Currently Entered:
0
digits.
CMC Student Email
*
Confirm Email Address
*
Parent Name
Parent Name
*
First
Middle
Last
Parent Email
*
Confirm Email Address
*
2019 Expenses
Name of the person/agency paid #1
*
Family member name #1
*
Date paid #1
Date paid #1
*
/
MM
/
DD
YYYY
Amount paid #1
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a second 2019 medical/dental expense?
*
Is there a second 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #2
*
Family member name #2
*
Date paid #2
Date paid #2
*
/
MM
/
DD
YYYY
Amount paid #2
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a third 2019 medical/dental expense?
*
Is there a third 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #3
*
Family member name #3
*
Date paid #3
Date paid #3
*
/
MM
/
DD
YYYY
Amount paid #3
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a fourth 2019 medical/dental expense?
*
Is there a fourth 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #4
*
Family member name #4
*
Date paid #4
Date paid #4
/
MM
/
DD
YYYY
Amount paid #4
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a fifth 2019 medical/dental expense?
*
Is there a fifth 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #5
*
Family member name #5
*
Date paid #5
Date paid #5
*
/
MM
/
DD
YYYY
Amount paid #5
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a sixth 2019 medical/dental expense?
*
Is there a sixth 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #6
*
Family member name #6
*
Date paid #6
Date paid #6
*
/
MM
/
DD
YYYY
Amount paid #6
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a seventh 2019 medical/dental expense?
*
Is there a seventh 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #7
*
Family member name #7
*
Date paid #7
Date paid #7
*
/
MM
/
DD
YYYY
Amount paid #7
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there an eighth 2019 medical/dental expense?
*
Is there an eighth 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #8
*
Family member name #8
*
Date paid #8
Date paid #8
*
/
MM
/
DD
YYYY
Amount paid #8
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a ninth 2019 medical/dental expense?
*
Is there a ninth 2019 medical/dental expense?
Yes
No
Family member name #9
*
Name of the person/agency paid #9
*
Date paid #9
Date paid #9
*
/
MM
/
DD
YYYY
Amount paid #9
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a tenth 2019 medical/dental expense?
*
Is there a tenth 2019 medical/dental expense?
Yes
No
Family member name #10
*
Name of the person/agency paid #10
*
Date paid #10
Date paid #10
*
/
MM
/
DD
YYYY
Amount paid #10
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there an eleventh 2019 medical/dental expense?
*
Is there an eleventh 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #11
*
Family member name #11
*
Date paid #11
Date paid #11
*
/
MM
/
DD
YYYY
Amount paid #11
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there a twelfth 2019 medical/dental expense?
*
Is there a twelfth 2019 medical/dental expense?
Yes
No
Name of the person/agency paid #12
*
Family member name #12
*
Date paid #12
Date paid #12
*
/
MM
/
DD
YYYY
Amount paid #12
*
$
Dollars
.
Cents
Only include out-of-pocket expenses
Is there any additional 2019 medical/dental expense?
*
Is there any additional 2019 medical/dental expense?
Yes
No
List all additional 2019 medical/dental expense with the name of person/agency paid, date paid, and amount paid
*
Total 2019 Medical/Dental Expenses
*
$
Dollars
.
Cents
Certification Statement
*
Certification Statement
We certify that the information listed above is a complete and accurate list of all out-of-pocket 2019 medical/dental expenses.