Form Dcd-0447 - Emergency Child Care Voucher
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1Attention Provider: Form Marked Original Must be Returned To:___________________________________
_______________________________________________________By (Date):____________________________
Address: ____________________________________________________________________________________
_______________________________________________________________ Voucher No.:_________________
EMERGENCY CHILD CARE VOUCHER
DIVISION OF CHILD DEVELOPMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICES
(PLEASE PRINT)
Child’s Name:_________________________________________________Child ID No.:____________________
Child’s Age and/or Date of Birth:_________________________________________________________________
Parent’s Name or Guardian’s Name:_______________________________________________________________
Address (indicate if a relative’s or friend’s address):__________________________________________________
____________________________________________________________________________________________
Telephone Number (indicate if relative’s or friend’s telephone number): (
)____________________________
Eligibility Period of Care: From:__________________Through:_____________________(
maximum of four months)
Hours Care is Needed: From___________________a.m./p.m. Through___________________a.m./p.m.
From___________________a.m./p.m. Through___________________a.m./p.m.
Parent’s or Guardian’s Name (Please print.):________________________________________________________
Signature of Parent/Guardian:______________________________________________Date Signed:____________
Agency Section: County:__________________________________Date Form Completed:___________________
FEMA Claim Number):____________________________________Family Case Number: EMERGY
CATEGORY CODE: 019
FUND SOURCE: 85
Need Code for Child Care and/or Transportation. Circle the code number(s) that apply.
# 851: 100% Care
# 852: 75% Care
# 853: 50% Care
# 859: Transportation
Agency Representative Signature:______________________________________________Date:_____________
Print Agency Representative Name:______________________________________________________________
To be completed by Child Care Provider:
Provider Name:_______________________________________________Telephone: (
)_________________
Name of Facility:______________________________________________________________________________
License No. or Facility ID No., if assigned:_________________________________________________________
County in which care is given:___________________________________________________________________
Location (address) of where child care is provided:___________________________________________________
____________________________________________________________________________________________
Owner/Sponsor of Program:______________________________________Telephone: (
)________________
Mailing Address:______________________________________________________________________________
Person Completing Voucher (Please print and sign name):_____________________________________________
____________________________________________________________________________________________
Provider’s Social Security No. or Tax ID No.:____________________
Date Child Enrolled:________________
COMMENTS: ______________________________________________________________________________
____________________________________________________________________________________________
Original: Local DSS/LPA
Copy: Provider
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DCD-0447 Rev. 10/02
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