Group And Family Day Care Home Billing Form - Accounting Department Seneca County Division Of Human Services

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Group and Family Day Care Home
Retur n Forms To:
Da y Car e Provider Name:
Week # 1 Weekl y Fee $
Attn : Accountin g Department
Cour t ordere d amt.
$
Senec a Count y Divisio n of Huma n Services
Address:
Subtrac t Paren t Fee
$
P.O . Box 690
Tota l Du e From DHS
$
Waterloo , Ne w York 13165-0690
Week # 2 Weekl y Fee
$
Paren t Name
Cour t ordere d amt.
$
Child:
Address:
Subtrac t Paren t Fee
$
Tota l Du e From DHS
$
Weekly
Total No. of
Date of
Part Day
Hours of Care
Daily Rate
Rate
Hourly Rate
Hours in
Service
Rate
$_______
Care
Beginning
End
Week #1 Total $
Mon.
Week #2 Total $
Tues.
Wed.
Total Due From DHS
Thur.
This Page $
Fri.
Sat.
Total Due From DHS
Sun.
From All Pages $
Weekly
Total No. of
Date of
Part Day
Hours of Care
Daily Rate
Rate
Hourly Rate
Hours in
Service
Rate
$_______
Care
Beginning
End
Mon.
Provider's Signature
Date
Tues.
Wed.
Thur.
Parent's Signature
Date
Fri.
Sat.
Sun.
Date
DHS Worker's Signature
Please:
*Use a separate form for each child.
*Parent Fee is to be deducted from the child spending the most time in daycare each week – please be consistent.
*Billing forms submitted without the parent’s signature will be returned.
* See reverse side for explaination of weekly/daily/part day/hourly determinations
CHECK FOR ACCURACY-INCOMPLETE / INACCURATE BILLS WILL BE RETURNED, CAUSING A DELAY IN PAYMENT FOR SERVICES RENDERED

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