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Cs 3657 - Private Child Care Receipt/verification

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Private Child Care Receipt/Verification

CHILDREN'S SERVICES

The information provided on this form will be used in determining eligibility for child care expense benefits under the Child and Youth

Support (CYS) Program. The collection, use and disclosure of your personal information is done under the authority of the Child, Youth

and Family Enhancement Act and is in compliance with the Freedom of Information and Protection of Privacy (FOIP) Act. If you have

any questions about the collection of this information, please contact your caseworker.

Please submit the completed and signed form to:

Attention:

Name of CYS Caseworker

Fax:

include the area code

Phone:

include the area code

Form to be completed by the Private Child Care Provider.

Name of Child Care Provider

Name of CYS Caregiver/Guardian

Month being reported

Year being reported

Child's Information

Name

surname

first name

middle name

Number of hours of care provided

Actual Monthly Cost

Total Amount Received

**Note: A separate form is required for each additional child.

Declaration and Signatures

I declare the information on this form is true and complete.

I understand that the Child and Youth Support Program may need to contact resources to verify the information I have

provided on this form.

I understand that giving false or incomplete information may result in recovery of overpayment and/or fraud charges.

Signature of Child Care Provider

date (yyyy/mm/dd)

Return this form to CFSA Office Address:

Worksite Name/Stamp

CS 3657 (2004/11)

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Cs 3657 - Private Child Care Receipt/verification

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