Child Care Expense Reimbursement Request Form

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County of Santa Clara
Purpose: This form is used to document child care expenses incurred by members of boards,
commissions, and committees created by the County Board of Supervisors and any subsidiary bodies,
as defined in the Brown Act, while in the performance of their official County duties. Public funds
should not be used for purposes that are personal in nature or that do not have clear business purpose.
Name of Claimant: _____________________________
Date: _________________________________
Name of Brown Act Body that Claimant Serves: __________________________________________________
Reimbursement is for reasonable, actual child care expenses incurred in the performance of official County duties
in compliance with the County’s Child Care Expense Reimbursement Policy, and is limited to four (4) hours per
child, per day, and the California Department of Education’s published part-time hourly Average Rate for Child
Care Centers in Santa Clara County, available at
(Effective 10/1/2015, $18.61 per
hour for children under 2 years of age, $14.60 for children 2 through 5, and $13.22 for children aged 6 to 13).
Requests must be submitted to the Secretary or Clerk assigned to the County Brown Act body the member serves
within 30 days from the date the expenses were incurred. Initial each item below to indicate each statement is true:
A. The expenses resulted from the performance of official County business.
Please indicate the Date: _______ Start Time: ______ Duration: ______ Location: _________________________
and the Type of the qualifying business activities performed (check all that apply below)
Attendance at a meeting of the Brown Act body you serve
Attendance at an inspection/site visit for Brown Act body business
Attendance at a meeting with County staff for Brown Act body business
Participation in Brown Act body delegation visits or special event activities
B. The expenses were incurred for the care of a child, under the age of 13, who is the Claimant’s dependent.
C. The provider of child care is not the Claimant’s spouse or a person whom the Claimant can claim as a dependent.
Name of Child
Age of
Name, Address, and Contact
Total Cost Incurred
of Care
Information of Care Provider
Name: _________________________
$ _______________________
Address: _______________________
NOTE: This request will not be
considered unless original /
itemized receipts are included
Phone: ________________________
with this form.*
*Child Care Expense Reimbursement requires that ORIGINAL/ITEMIZED RECEIPTS, reflecting the actual
costs incurred, be submitted with this Form. Any of the following will be accepted as receipts: receipt indicating
who was paid and dollar amount, cash register receipt, copy of cancelled check, copy of bank statement if cancelled
check is not available, or an invoice marked paid or indicated how paid (cash, check, charge, etc.).
I certify that the above is true and correct and that the amount
Signature: _____________________________
claimed is for the reasonable and necessary expenses incurred,
solely for official County business and not personal use.
Verified by:
Approved by:
SAP Vender #:
SAP Document #:


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Parent category: Business