Form DHS 9800 A2D Daily Child Attendance Form - Arkansas

Form DHS9800 A2D is a Arkansas Department of Human Services form also known as the "Daily Child Attendance Form". The latest edition of the form was released in July 1, 2007 and is available for digital filing.

Download a PDF version of the Form DHS9800 A2D down below or find it on Arkansas Department of Human Services Forms website.

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DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILDCARE & EARLY CHILDHOOD EDUCATION
DAILY CHILD ATTENDANCE FORM
Facility Name_____________________ Facility Number ___________ Date of Service ____________
Parent/Guardian/Authorized Representative Certification of Attendance:
By my signature below, I declare
under penalty of perjury that the information is true and that my child/children were provided services at the above
location and on the days and times listed below. I understand that I must repay any overpayment resulting from false or
incorrect information and that I may be prosecuted for fraud.
Child's Name
Time In
Parent Signature**
Time Out
Parent Signature**
1
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5
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Provider Certificaiton: I declare under penalty of perjury that the above information is true and that these children were provided services at the above location and
on the days and times listed above. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for
fraud.
Director/Owner Signature
Date
DHS 9800 A2D (7/1/2007)
**Parent signature is required as disclosed in the 9800 agreement for payment of vouchers.
DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILDCARE & EARLY CHILDHOOD EDUCATION
DAILY CHILD ATTENDANCE FORM
Facility Name_____________________ Facility Number ___________ Date of Service ____________
Parent/Guardian/Authorized Representative Certification of Attendance:
By my signature below, I declare
under penalty of perjury that the information is true and that my child/children were provided services at the above
location and on the days and times listed below. I understand that I must repay any overpayment resulting from false or
incorrect information and that I may be prosecuted for fraud.
Child's Name
Time In
Parent Signature**
Time Out
Parent Signature**
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Provider Certificaiton: I declare under penalty of perjury that the above information is true and that these children were provided services at the above location and
on the days and times listed above. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for
fraud.
Director/Owner Signature
Date
DHS 9800 A2D (7/1/2007)
**Parent signature is required as disclosed in the 9800 agreement for payment of vouchers.

Download Form DHS 9800 A2D Daily Child Attendance Form - Arkansas

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