Form DHS9800 A2D "Daily Child Attendance Form" - Arkansas

What Is Form DHS9800 A2D?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2007;
  • The latest edition provided by the Arkansas Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS9800 A2D by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form DHS9800 A2D "Daily Child Attendance Form" - Arkansas

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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**
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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.