Sacramento County Child Care Payment Request Form


Download Sacramento County Child Care Payment Request Form


Preview text

Sacramento County Child Care Payment Request Form
--Use One Form For Child – PLEASE MAIL THIS FORM TO: DHA PO BOX 487 SACRAMENTO, CA 95812-9874

Month/Year of Care:

Please sign child in and out of care daily. The first initial of your first name and your last name are required.

● Do not use “white-out”. Days marked with “white-out” will not be paid.

● Only list hours of care the child actually used each day.

● Both sides of this payment request form must be completed, signed and dated on or after the last day care was provided.

● Payment will be delayed if this form is incomplete.

● Each day the child does not use care as scheduled, enter one of the following codes in the “Code” box on the reverse side and

include the number of hours the child had been scheduled to attend daycare. These codes are for licensed providers only.

Provider Closed All or Part of the Day
C

Child or Parent ill and Child did not Attend Daycare
S

Child Absent for Other Reasons
A

School-Age Child did not Attend School Due to Illness but did Attend Daycare
D

Minimum Day M

Non-school Day
NS

Parent Information: (To be completed by parent) Parent 1 Name:

Child Information: Child’s Name:

Parent 1 Activity: □ Employment □ School □ CWEX □ JC

Child’s Home Address:

Activity Schedule:

Phone #:

Activity Address:

School:

Parent 2 Name (if in the home): □ not in home

Grade:

Parent 2 Activity: □ Employment □ School □ CWEX □ JC

Date of Birth:

Age:

Activity Schedule: Activity Address:
Travel Time: From day care to activity is ____________ minutes each way.

Parent Mode of Transportation: □ Drive □ Walk □ Bus
□ Other ________________________

Child Care Provider Information: (To be completed by provider)

Type of Facility:

□ Child Care Center □ Licensed Family Child Care Home □ Trustline Provider

□ Relative

Provider Name:

DBA (Doing Business As Name):

County Use: WTW HSS Code: _________________ Case Name: _________________ Case #: _________________ Date Received: _________________ Timesheet # _________________ Family ID ________ Child ID _________ Provider ID_______

Address Where Care is Provided: □ New Address
City, State & Zip:

Provider Billing Address: □ New Address
Day Care License Number:

Phone:

If relative, relationship:

Last four digits of provider’s SSN or Tax ID if incorporated

Child Care Provider Billing: (To be completed by provider)
Please fill out your billing amount in the appropriate categories. All charges must match what appears on your rate sheet if you wish payment to be made.

□ Monthly Rate: $

Weekly Rate: $

□ Daily Rate:

$

Hourly Rate: $

□ Evening Rate: (6:00 pm to 6:00 am) $ ________ Sat/Sun Rate: $

□ Registration Fee for licensed providers as charged per rate sheet: $

Month Annual Registration is due as billed per Rate Sheet: _______________________

Total billed for this month for child $ _______________________

IMPORTANT NOTICE: RETURN THIS FORM BY
THE 5TH DAY OF THE MONTH FOLLOWING THE
MONTH CHILD CARE WAS PROVIDED.
BOTH SIDES OF THIS PAYMENT REQUEST
FORM MUST BE COMPLETED, SIGNED AND DATED BY BOTH THE PROVIDER AND THE PARENT, ON OR AFTER THE LAST DAY CARE
WAS PROVIDED.

I declare under penalty of perjury under the laws of the United States and the State of California that the facts contained in this payment request form

are true and correct and complete for the entire month.

___________ ______________

______________________ ____________

Parent Signature

Date

Provider Signature

Date

CCP 2145_34F (01/12)

To be completed by parent:

Month/Year

Start on the 1st day of care in the month, sign your child in and out daily by filling in the date of care, the time the child was dropped off

and picked up and your signature (first name initial and last name). For each day when care was provided, fill in the total daily hours of

care in the “Hours” box. Also, fill in the hours scheduled for any absence days. At the end of each week, fill in the “Total Hours” box

listed in the left column.

Sunday

Monday

Tuesday

Wednesday Thursday Friday

Saturday

Date

Time In

Signature

Time Out

Signature

Total Hours

Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code

Date Time In Signature Time Out Signature
Total Hours

Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code

Date Time In Signature Time Out Signature
Total Hours

Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code

Date Time In Signature Time Out Signature
Total Hours

Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code

Date Time In Signature Time Out Signature
Total Hours

Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code Hours Code

Total hours of care this month __________________________________
I declare under penalty of perjury under the laws of the United States and the State of California that the facts contained in this payment request form are true and correct and complete for the entire month.

__________________________________ Parent Signature

_____________ Date

_____________________________________ Provider Signature

_____________ Date

CCP2145_34F(01/12)

Preparing to load PDF file. please wait...

0 of 0
100%
Sacramento County Child Care Payment Request Form