Childcare Billing Form - Seneca County
ADVERTISEMENT
1Group and Family Day Care Home
Return Forms To:
Day Care Provider Name:
Week #1 Weekly Fee $
Attn: Accounting Department
Court ordered amt. $
Seneca County Division of Human Services
Address:
Subtract Parent Fee $
P.O. Box 690
Total Due From DHS $
Waterloo, New York 13165-0690
Week #2 Weekly Fee $
Parent Name
Court ordered amt. $
Child:
Address:
Subtract Parent Fee $
Total Due 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.
DHS Worker's Signature
Date
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Wtw 39 - Assembly Bill (ab) 74 County Welfare Department (cwd) Expanded Subsidized Employment (ese) Plan
Legal
Form Dci-67 - Criminal History Record Check Billing Form - Iowa Division Of Criminal Investigation
Legal
Related Categories
Parent category: Legal