Application For Housing Benefit, Local Housing Allowance And Council Tax Reduction - Carmarthenshire County Council Page 31
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32HBD
Name of Applicant:
Address:
NOTE TO APPLICANT: Please ask the person or organisation providing the child care to complete this form.
Please ensure both you and your childcare provider sign the declarations below.
Please tick the type of childcare that applies to you:
Registered childminder caring for
Nursery or play scheme on
your child in your home or their home
government property
Registered nursery care for your child
Out of hours club run by Local
on nursery premises
Authority
Registered play scheme
Out of hours club at school
Other (please describe type of care):
Please give us the name and the address of the Child Care Provider:
Phone number of premises:......................................
Please fill in the following for each child that you pay childcare for. For more than one child please request
additional forms
Child’s full name
Number of days the child attends per week
Full days
Half Days
Number of weeks the child attends during the year
Weekly Charge (term time)
£
Number of weeks at this rate
Weekly Charge (School Holidays)
£
Number of weeks at this rate
Date started paying child care costs
Are there any periods when you do not pay for childcare
Please give details of any future changes/ or recent
changes
Date of last increase/decrease and rates changed from
If childcare fluctuates on a regular basis please provide a breakdown of the charges for the last 6 months.
CLAIMANTS DECLARATION: I have carefully checked the information on this form and declare it is true
and complete to the best of my knowledge. I know I must notify the council in writing straight away
of any changes that happen.
Claimants Signature
Date
CHILDCARE PROVIDERS DECLARATION: I confirm the above information is true and complete
Name (Please Print)
Signature
Date
Official Stamp (If Available)
31
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Parent category: Financial