Child Care Verification Form printable pdf download

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 ●

Child Care Verification Form