Microsoft Word - DOL CCSP Monthly Invoice Form_3

DOL Child Care Subsidy Program

Monthly Invoice Form

SECTION A – EMPLOYEE (Parent ) AND CHILD CARE PROVIDER INFORMATION

1. PARENT’S DOL CODE 2. PARENT'S FIRST NAME PARENT’S LAST NAME

BLS

3. INVOICE

MONTH

4. INVOICE

YEA

5. NAME OF CHILD CARE PROVIDER (Individual name if you are not a business)

SECTION B - CHILDREN INFORMATION

Please list each child of the DOL employee listed above on line 3, for whom child care services were provided by the child care provider listed above

on line 5. You may list up to 4 children on the same invoice as long as all of the children were cared for by the same child care provider.

CHILD 1 FIRST NAME CHILD 1 LAST NAME CHILD 1 AGE

CHILD 2 FIRST NAME CHILD 2 LAST NAME CHILD 2 AGE

CHILD 3 FIRST NAME CHILD 3 LAST NAME CHILD 3 AGE

CHILD 4 FIRST NAME CHILD 4 LAST NAME CHILD 4 AGE

SECTION C - CHILD CARE SERVICES WEEKLY COST AND TOTAL MONTHLY COST

Please indicate the total child care charges for services rendered each week during the month. Each week is from Monday to Friday. Please look at

a calendar each month, and count the number of Fridays in the month. The week ending date should always be on a Friday. Most months will have

4 Fridays or 4 weeks. A few months will have 5 weeks. PLEASE DO NOT PUT DIFFERENT MONTHS ON THE SAME INVOICE.

CHILD 1 CHILD

CARE COST

CHILD 2 CHILD

CARE COST

CHILD 3 CHILD

CARE COST

CHILD 4 CHILD

CARE COST

TOTAL WEEKLY CHILD

CARE COST

WEEK 1 ENDING DATE

WEEK 2 ENDING DATE

WEEK 3 ENDING DATE

WEEK 4 ENDING DATE

WEEK 5 ENDING DATE

TOTAL CHILD CARE CHARGES FOR THE MONTH

$

SECTION D - EMPLOYEE

PARENT

CERTIFICATION

I certify that the above information is true and complete to the best of my knowledge. I certify that I am an active full-time or part-time permanent U.S.

Department of Labor (DOL) employee, and my total family or adjusted gross income (including my spouse's income) does not exceed $79,999 per year . I

certify that I am the parent or legal guardian of each child listed above. I certify that each child listed above is under age 13 (under age 18 if my child is

disabled). I certify that each child listed above was cared for by the child care provider listed above, and I confirm each child’s attendance as indicated above.

I understand that if I make a false statement, it is a violation of federal law and I may be subject to criminal and / or civil penalties as allowed by law. In

addition, I further understand that if I make false statements or misrepresentations on this form, I may be subject to criminal prosecution and punishment,

including the termination of my employment, fines, repayment of any child care subsidies received, or imprisonment.

SIGNATURE OF PARENT / GUARDIAN DATE SIGNED

SECTION E - CHILD CARE PROVIDER CERTIFICATION

I certify that I have the legal authority to sign on behalf of the child care facility listed above, or I am the person who is providing child care services. I

further certify that the above information is true and complete to the best of my knowledge. I certify that I (we) am (are) a licensed or regulated child care

provider; or I am an eligible child care provider pursuant to requirements of my state. I certify and affirm that I am not receiving a child care subsidy or child

care benefit from any other source for any of the children listed above, except any other child care subsidy that I have disclosed to FFA. I certify that each

child listed above did attend my facility (or home) as indicated above, and I (we) did provide child care services for each child listed above.

I understand that if I make a false statement, it is a violation of federal law and I may be subject to criminal and / or civil penalties as allowed by law. In

addition, I further understand that if I make false statements or misrepresentations on this form, I may be subject to criminal prosecution and punishment,

including repayment of any subsidies received, fines or imprisonment.

SIGNER’S PRINTED SIGNATURE TITLE DATE SIGNED