CHILD CARE VERIFICATION FORM
Verification of amount paid for care of children or dependent person(s)
This form must be returned whenever a deduction from income is requested along with applicable verification
forms. The day care provider completes the form. If the day care provider is unlicensed or is related to the
family, this form must be notarized.
I, __________________________________________________, License Number _____________________,
Phone No. ______________________________________________, do hereby certify that I provide childcare
For:______________________________________________________________________________________
(Name of Parent whose children or dependent person(s) are provided for?)
CHILD’S NAME
AGE
NUMBER OF HOURS PER WEEK
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Amount received for childcare from Parent? $ ________________ per ________________
Amount received for childcare from other’s on behalf of this Family? $_________________per ______
Estimated cost for childcare in the next 12 months: $______________________________________________
(Please include full-time summer care of school children)
JURAT NOTARIZATION
State of _________________________
County of ________________________
(Day Care Provider’s Name) : _______________________________________________________________________, after first
being by me duly sworn, affirms and declares that the statements in this document are true.
________________________________________
______________________
Day Care Provider Signature
Date
Subscribed and sworn (affirmed) before me, a Notary Public, in and for the State of _____________ this day of _______ 20_____.
_____________________________________________________________
Notary Public
Notary Commission Expires: _____________________________________
Longmont Housing Authority and Longmont Housing Development Corporation
1228 Main Street, Longmont, CO 80501 ● PH: 303-651-8581 ● FAX: 303-682-2899 ● TTY: 711 ●