E-Child Care Provider Payment Discrepancy Form Page 2

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E-C
C
A
L
HILD
ARE
TTENDANCE
OG
Return to:
County:
Camden County Department of Children's Services
512 Lakeland Road - DiPiero Center - Suite 200 - Blackwood, NJ 08012
Camden
Phone: 856.374.6376
Fax: 856.374.6384
EPPIC #:
Provider Name:
Phone:
Site / Location Address:
Parent’s Name:
Child’s Name:
Case #:
 WFNJ
 CCAP
 CPS or PACC
 DOE Wrap
Please Check One
This attendance log is a backup form and specific to ECC. This form does not replace the parents’ requirement to check their child in and
out daily using the ECC system. Please return form along with discrepancy form when information is not properly recorded in ECC.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Week of:
Check-In Time
Check-Out Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Week of:
Check-In Time
Check-Out Time
I CERTIFY THIS IS AN ACCURATE ACCOUNT OF ATTENDANCE FOR THE CHILD REFERENCED ABOVE.
(Both the Parent and Provider must sign and date below!)
Parent/Guardian Signature
Date:
Provider Signature
Date:
FOR OFFICE USE ONLY (Do not write below this line)
Total # of Days
Daily Rate
Total Adjustment Due
Comments:
Prepared By:
Date:

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