Form A-75ocs - Reimbursement Voucher For Overnight Childcare For Policy Council Members

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A-75ocs (Rev for 1/1/16)
Capital Region ESD 113 Sound to Harbor Head Start/ECEAP
Reimbursement Voucher for Overnight Childcare for Policy Council Members
Funding Source:
Head Start
ECEAP Activity: ______________________________________________ Dates: ________________________
Center: _____________________________________________ Print Parent’s Name: __________________________________________________
Child care will be reimbursed for approved parent activities. Children, spouses or live-in relatives are not eligible for child care compensation.
Their time may be counted as in-kind contributions to the program.
CHILD CARE RATES for OVERNIGHT CARE
1 child = $24.00
2 children = $45.00
3 children = $65.00
4 or more children = $85.00
Number of
Payable to Child Care Provider
Number of
Amount Due
Check #
Days of
Amounts
PRINT Child Care Provider’s First & Last Name
Children
Per Number of Children
Child Care
$______ x ____ =
$
Rate
Days
$______ x ____ =
$
Rate
Days
$______ x ____ =
$
Rate
Days
MILEAGE
Payable to Driver (Print First & Last Name below)
Check #
Number of miles driven: _________ x 0.54¢ = $
I, the undersigned, do hereby certify under penalty of perjury that this claim is a just, due, and unpaid obligation of ESD 113, and that I am
PARENT’S SIGNATURE: ____________________________________________________ Date: ____________
authorized to certify said claim.
Parent’s mailing address (please print):____________________________________________________________ City & Zip: ___________________
Solicitud de reembolso para padres del Consejo de Política por el cuidado de niños/guardería por la noche
Fuente de financiamiento:
Head Start
ECEAP Actividad: ____________________________________________________ Fechas: ___________
Centro: ___________________________________ Nombre del Padre (Use letra de molde): ____________________________________________
Se reembolsarán los gastos de cuidado de niños para las actividades de padres aprobadas. No pueden recibir reembolso de gastos de cuidado
de niños los niños o esposos ni los parientes que viven con la familia. El tiempo de estas personas puede ser contado como una contribución en
especie al programa.
COSTO por CUIDADO DE DE NIÑOS/GUARDERÍA DURANTE LA NOCHE
1 niño = $24.00
2 niños = $45.00
3 niños = $65.00
4 niños o más = $85.00
Número de Días
Pago al Proveedor de Cuidado de Niños
Número
Cantidad Debida
en el cuidado de
Cantidad
Use Letra de Molde: Nombre & Apellido
Cheque #
de niños
Por Número de Niños
Niños o Guardería
del Proveedor de Cuidado de Niños
$______ x ____ =
$
Tarifa
Días
$______ x ____ =
$
Tarifa
Días
$______ x ____ =
$
Tarifa
Días
Pago al Conductor/Chofer (Nombre & Apellido -
Cheque #
MILLAS
Use Letra de Molde en la casilla de abajo)
Número de millas viajadas
: _________ x 0.54¢ = $
Al firmar abajo y por medio de la presente certifico, bajo pena de perjurio, que esta solicitud es justa y representa una obligación adeudada y no
pagada del ESD 113 y que tengo autorización para certificar dicha solicitud.
FIRMA DEL PADRE, MADRE O TUTOR:
Fecha: ________________
___________________________________________________________________________ ____________________________________________
Dirección postal del padre (por favor use letra de molde)
Ciudad y Código postal
Forms\Admin\A-75ocs Reimbursement Voucher for Overnight Childcare for PC Members (dual language)

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