Fillable Child Care Expense Reimbursement Request Form printable pdf download

County of Santa Clara

CHILD CARE EXPENSE REIMBURSEMENT REQUEST FORM

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:

Initial

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

Initial

B. The expenses were incurred for the care of a child, under the age of 13, who is the Claimant’s dependent.

Initial

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

Hours

Name, Address, and Contact

Total Cost Incurred

Child

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.*

PLEASE INCLUDE ADDITIONAL PAGES AS NEEDED

*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.).

Claimant

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.

Date:

Verified by:

Date:

Approved by:

Date:

SAP Vender #:

SAP Document #:

10/12/2016

Child Care Expense Reimbursement Request Form

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