Sacramento County Stage One Child Care - Request for ...
Sacramento County Stage One Child Care - Request for Reimbursement 2145 Form
Month/Year of Care
SUBMIT COMPLETE FORM TO: DHA, 7405 Greenhaven Drive, Sacramento, CA 95831 or DHA-Child-Care-2145s@
? Sign child in and out of care daily using your first initial and last name OR full signature. Only enter in and out times for the hours of care child actually uses.
? Do not use ¡°white-out¡±. Days marked with ¡°white-out¡± will not be paid. Complete this form in blue or black ink only.
? Both sides must be complete, and the front must be signed and dated by both the provider and the parent on or after the last day of care. All forms must be
received no later than 3 months after care took place for payment to be made. If this form is received late or incomplete, payment will be denied.
? Check that all hours/days/weeks entered in Section 4 - Billing Summary below matches the hours/days/weeks of care used on the back.
? Each day the child does not use care as scheduled and payment is expected, enter one of these codes in the ¡°Reason Code¡± box on the reverse:
Child or parent ill & child was not Provider closed all or part of
the day
in care all or part of day
S
C
Child absent for other
reasons
A
School-age child did not attend school
School Minimum Day
due to illness but was in care
D
Non-School Day
M
SECTION 1 AND 2 TO BE COMPLETED BY PARENT ONLY
SECTION 1 Parent Information
SECTION 2 Child Information
Parent 1 Name:
Child's Full
Other
Work
School
CWEX
Job Club
Activity Type:
Name:
Activity Name:
Child's Home
Activity Address:
Address:
City, State & Zip:
City, State & Zip:
Phone:
Activity Schedule
Date of Birth:
Age:
(indicate days & times):
Parent 2 Name (if in the home):
Check here if
School
not in the home
Name:
School
CWEX
Other
Activity Type:
Work
Job Club
Track:
Grade:
Case
#:
Activity Name:
Travel time from provider to activity
Activity Address:
is
_____________________
City, State & Zip:
CCPU HSS¡õ:
Minutes each way.
Activity Schedule
(indicate days & times):
NS
COUNTY USE
ONLY
FID:
CID:
PID:
TID:
County Date Stamp:
¡õ
SECTION 3 AND 4 TO BE COMPLETED BY PROVIDER ONLY
SECTION 3 Child Care Provider Information
SECTION 4 Child Care Provider Billing Summary
Type of Provider:
Licensed Family Child
Care Home
Child Care
Center
Relative
Provider**
TrustLine
Provider
**Must be by blood, marriage, or
legal decree, and verifiable. All other
relationships check TrustLine
Provider.
$
$
$
$
$
$
$
$
Evening Rate: $
Weekend Rate: $
Doing Business
As (DBA) Name:
Last four digits of provider's
SSN or Tax ID if incorporated:
Check here if new address:
City, State & Zip:
Provider's Billing Address:
Check here if new address:
Monthly Rate: $
Weekly Rate:
Weekly Rate:
Weekly Rate:
Weekly Rate:
Daily Rate:
Daily Rate:
Hourly Rate:
Hourly Rate:
Provider Name:
Address Where Care is Provided:
Enter all numbers as decimals. If completed electronically, the worksheet will calculate as currency &
compute a Total Billed amount at the bottom. If completed by hand, calculate totals in currency, add up
all amounts entered, and enter a total in the Total Billed section at the bottom. For Evening & Weekend
Rates, enter a unit type in the empty box, i.e. hours, days, etc.
ONLY ENTER AMOUNTS YOU ARE ACTUALLY BILLING.
X
X
X
X
X
X
X
X
X
X
Month =
Weeks =
Weeks =
Weeks =
Weeks =
Days =
Days =
Hours =
Hours =
Registration Fee due for licensed providers as per rate sheet:
Month Annual Registration Fee is due as per rate sheet:
City, State & Zip:
Phone Number:
TOTAL BILLED FOR THIS MONTH:
By signing, we declare under penalty of perjury under the laws of the United States and State of California that the information I provided on the front and back of this form are
true, correct, and complete for the entire month. Any fraud of government funds will result in criminal prosecution to the full extent of the law.
Parent Signature
CCP 2145 (07/20)
Date
Provider Signature
Date
Month/Year: _____________ COMPLETE IN HOURS & MINUTES ONLY
Child's First and Last Name:
Start on the 1st day of care in the month. Fill in time child was dropped off & picked up, & sign on each day care took place.
*By initialing and/or signing this form each day, you declare under penalty of perjury under the laws of the United States and the State of California that the facts each
day are true, correct, and complete. Any fraud of government funds will result in criminal prosecution to the full extent of the law.
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CCP 2145 (07/20)
Time
In
Time Out
Circle
AM or PM
AM
PM
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PM
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PM
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PM
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Signature* of adult signing
out child
TOTAL HOURS OF CARE FOR THE MONTH:
Total
Hours
COUNTY
USE ONLY
3
AM
PM
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PM
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Time
Out
Sign Out DAILY
Initials*
2
Circle
AM or PM
Signature* of adult signing
in child
Initials*
Day of
Week
Date
1
Time In
Use ONLY if child
has split schedule
Reason Code
Sign In DAILY
................
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