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Stabilization Funds - Additional Info needed
License Type
(Required)
Please Select
DCCC
DCFH
DCEX
DCGH
License Number
(Required)
In order to conduct this review. You must provide at least one document from two (2) of the following 5 categories:
Category 1 - Attendance records indicating children in attendance
This may include;
electronic payment documents including invoice and provider or parent credit card statement
venmo, paypal (or other financial transaction app) screen shot listing the payment
handwritten receipt for services
Category 2 - Financial record indicating payment for services delivered
This may include;
Signed and dated attendance records maintained by the provider; signed and dated attendance records with family signatures.
Handwritten attendance forms with parent signatures are acceptable, if there are no parent signatures, a second form of documentation is required.
Electronic attendance system records do not require a signature.
Category 3 - Formal Correspondence that shows a conversation between a family and the provider regarding a child’s attendance at the program
This may include;
emails
signed and dated notes
documents on program letterhead
program forms such as care plans, between provider and family
Category 4 - Enrollment forms
This may include;
Documents showing the child’s name and schedule, corresponding to a financial payment, attendance record, correspondence, or family attestation.
Category 5 - Parent/Guardian or Third Party attestation
This must include the Open-Closed-Proof-of-Documentation-Form (
click here to download
);
Open/Closed Verification Form signed by parent or guardian or approved third party.
-OR-
Licensing Inspection document
Reflecting children in attendance on the date of the inspection (One document will meet evidence requirement for one week in question)
Attach documents here
(Required)
Please attach all corresponding documents related to the items you checked above.
Drop files here or
Select files
Accepted file types: jpg, doc, pdf, png, gif, Max. file size: 10 MB, Max. files: 4.
Contact Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Additional notes or comments
Any incomplete submissions will not be considered.
You will receive a response with the outcome of your dispute within 2 weeks of the date submitted.
The Submit button will become active when you select one of the category items above.
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