Child Care Claim - Oklahoma Department Of Human Services Page 2
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210AD121E (ADM-12-S)
Child Care Claim
Part IV. Attendance record
Child's name
Date of birth
Case/person no.
Authorization no.
Time
Time
Time
Time
Time
Time
Time
Time
Date
Date
in
out
in
out
in
out
in
out
1
a p
a p
a p
a p
17
a p
a p
a p
a p
2
a p
a p
a p
a p
18
a p
a p
a p
a p
3
a p
a p
a p
a p
19
a p
a p
a p
a p
4
a p
a p
a p
a p
20
a p
a p
a p
a p
5
a p
a p
a p
a p
21
a p
a p
a p
a p
6
a p
a p
a p
a p
22
a p
a p
a p
a p
7
a p
a p
a p
a p
23
a p
a p
a p
a p
8
a p
a p
a p
a p
24
a p
a p
a p
a p
9
a p
a p
a p
a p
25
a p
a p
a p
a p
10
a p
a p
a p
a p
26
a p
a p
a p
a p
11
a p
a p
a p
a p
27
a p
a p
a p
a p
12
a p
a p
a p
a p
28
a p
a p
a p
a p
13
a p
a p
a p
a p
29
a p
a p
a p
a p
14
a p
a p
a p
a p
30
a p
a p
a p
a p
15
a p
a p
a p
a p
31
a p
a p
a p
a p
16
a p
a p
a p
a p
I certify the information recorded above accurately documents the days and hours care
was provided. I certify I have signed and dated the form after care was provided for the
month indicated in the Attendance Record section of the form. I certify that I have paid or
made arrangements to pay my family share co-payment, if applicable.
I affirm under penalty of perjury that the information contained on this form is correct to
the best of my knowledge and belief. I understand any false statements on my part,
including the filing of erroneous claims, may result in prosecution for fraud.
Client, parent, guardian, or caretaker signature
Date
I, the child care provider, certify the information recorded on this form accurately
documents the dates and times care was provided, and that I have made every
reasonable effort to secure the signature of the client, parent, guardian, or caretaker
and have been unsuccessful in that effort. I further understand that I may sign below
only when the child has left my care and I will not be requesting further payment.
Provider signature, complete only when unable to obtain a signature
Date
Total full
$
Part V. For office use only
Total part
$
FPW #:
X $
= $
Total week
$
Less co-pay
$
FPW #:
X $
= $
Claimed
$
2
OKDHS revised 8-14-2006
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