Form DCF-F-2630 "Removal of Records Receipt - Child Care Centers" - Wisconsin

What Is Form DCF-F-2630?

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

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the Wisconsin Department of Children and Families;
  • 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 DCF-F-2630 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Children and Families.

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Download Form DCF-F-2630 "Removal of Records Receipt - Child Care Centers" - Wisconsin

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DEPARTMENT OF CHILDREN AND FAMILIES
dcf.wisconsin.gov
Division of Early Care and Education
Removal of Records Receipt – Child Care Centers
Use of form: Under the authority of s. 48.66(1)(a), Wis. Stats., and DCF 201, 202, 250, 251, and 252 Wis. Admin. Codes, the child
care administrative agency is removing original records for the purposes of administrative review and / or audit.
Instructions: The agency employee removing the original records will complete the form, sign and date it and obtain a signature
from the licensee or certified provider. The original copy of the form will be left with the licensee or certified provider who must retain it
as proof that the facility / provider is not out of compliance with record keeping rules.
LICENSEE / PROVIDER INFORMATION
Facility ID / Provider Number
Name – Facility / Business
Name – Licensee / Provider
Address – Facility / Location (Street, City, State, Zip
Code)
RECORDS INFORMATION
Date range of records requested
Type of original records removed:
Attendance Records
Children’s Records
Staff Records
s
Payment Agreement
Computerized Records
EBT Cards
Parent Account Information
Provider Policy Documents
Other (explain)
Transportation Records (If checked, see below)
This facility is approved to provide transportation but does not use Wisconsin Shares funds for providing transportation.
This facility is approved to provide transportation and does use Wisconsin Shares funds for providing transportation.
Dates or date ranges of records removed
Dates or date ranges of records missing from the files
Number of pages collected:
Other Information (if required)
ADMINISTRATIVE AGENCY INFORMATION
Name – Agency
Name – Agency Employee
Address – Agency (Street, City, State, Zip Code)
Telephone Number – Agency
ATTESTATION
A.
Licensee / Provider
Yes
N/A I acknowledge that because I am unable to provide the missing records at this time, that even if the
missing records are later submitted, the agency may not consider the submitted records as legitimate.
Yes
N/A Except where noted above, I confirm that the records I am providing are all of the records used to
support the attendance requirements of the Wisconsin Shares Subsidy Program.
I attest that I have no child care EBT cards or card information (this includes copies, documents, or photos of
account numbers, PINs) in my possession.
I attest that the information contained on this form is correct and complete to the best of my knowledge.
Name – Licensee / Provider (PRINT)
Title – Licensee / Provider
SIGNATURE – Licensee / Provider
Date and Time Signed
B.
Administrative Agency
In compliance with Wisconsin statutes and administrative codes, the child care provider has voluntarily provided the
above-mentioned records to this agency.
Name – Agency Employee (PRINT)
Title – Agency Employee
SIGNATURE – Agency Employee
Date and Time Signed
Distribution:
White – Center Representative / Certified Provider; Pink – Administrative Agency
DCF-F-2630 (R. 7/2018)
DEPARTMENT OF CHILDREN AND FAMILIES
dcf.wisconsin.gov
Division of Early Care and Education
Removal of Records Receipt – Child Care Centers
Use of form: Under the authority of s. 48.66(1)(a), Wis. Stats., and DCF 201, 202, 250, 251, and 252 Wis. Admin. Codes, the child
care administrative agency is removing original records for the purposes of administrative review and / or audit.
Instructions: The agency employee removing the original records will complete the form, sign and date it and obtain a signature
from the licensee or certified provider. The original copy of the form will be left with the licensee or certified provider who must retain it
as proof that the facility / provider is not out of compliance with record keeping rules.
LICENSEE / PROVIDER INFORMATION
Facility ID / Provider Number
Name – Facility / Business
Name – Licensee / Provider
Address – Facility / Location (Street, City, State, Zip
Code)
RECORDS INFORMATION
Date range of records requested
Type of original records removed:
Attendance Records
Children’s Records
Staff Records
s
Payment Agreement
Computerized Records
EBT Cards
Parent Account Information
Provider Policy Documents
Other (explain)
Transportation Records (If checked, see below)
This facility is approved to provide transportation but does not use Wisconsin Shares funds for providing transportation.
This facility is approved to provide transportation and does use Wisconsin Shares funds for providing transportation.
Dates or date ranges of records removed
Dates or date ranges of records missing from the files
Number of pages collected:
Other Information (if required)
ADMINISTRATIVE AGENCY INFORMATION
Name – Agency
Name – Agency Employee
Address – Agency (Street, City, State, Zip Code)
Telephone Number – Agency
ATTESTATION
A.
Licensee / Provider
Yes
N/A I acknowledge that because I am unable to provide the missing records at this time, that even if the
missing records are later submitted, the agency may not consider the submitted records as legitimate.
Yes
N/A Except where noted above, I confirm that the records I am providing are all of the records used to
support the attendance requirements of the Wisconsin Shares Subsidy Program.
I attest that I have no child care EBT cards or card information (this includes copies, documents, or photos of
account numbers, PINs) in my possession.
I attest that the information contained on this form is correct and complete to the best of my knowledge.
Name – Licensee / Provider (PRINT)
Title – Licensee / Provider
SIGNATURE – Licensee / Provider
Date and Time Signed
B.
Administrative Agency
In compliance with Wisconsin statutes and administrative codes, the child care provider has voluntarily provided the
above-mentioned records to this agency.
Name – Agency Employee (PRINT)
Title – Agency Employee
SIGNATURE – Agency Employee
Date and Time Signed
Distribution:
White – Center Representative / Certified Provider; Pink – Administrative Agency
DCF-F-2630 (R. 7/2018)