Child Care Verification (Page 2 of 2) in pdf

Child Care Verification Page 2

STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES

DIVISION OF CHILD SUPPORT (DCS)

Child Care Verification Response

Complete a separate form for each child listed on page 1.

DCS Case Number

Child Care Provider Name and Address

Child Care Provider Telephone Number (include area code)

(

)

Child's Name

I am paid $

per

for this child. Of this amount, I receive

subsidy from Washington State or another state or government agency per month for this child.

Enter the amounts you received from the custodian that Washington State or any other state or government agency did

not subsidize. This page has space for 12 months of payments. Attach additional sheets if needed.

Amount

Period (month/year)

Amount

Period (month/year)

I declare under penalty of perjury, under the laws of the state of Washington, that the foregoing is true and correct. I

understand that DCS will use the information I have provided for child support purposes and will become public record.

DCS may disclose the information to the noncustodial parent upon written request to DCS and pursuant to public

disclosure policy.

Date

Child Care Provider Signature

Child Care Provider Printed Name

Date

Parent / Custodian Signature

Parent / Custodian Printed Name

(1.7)

FG VER:

CHILD CARE VERIFICATION

Page 2

DSHS 18-607 (REV. 05/2015)

Child Care Verification Page 2