"Proof of Child Care Costs Form" - Peterborough, Cambridgeshire, United Kingdom

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Download "Proof of Child Care Costs Form" - Peterborough, Cambridgeshire, United Kingdom

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PROOF OF CHILD
AB
CARE COSTS
Claim ref: __________________________
(To be completed by the child care provider)
Parent/Guardian Name(s):
___________________________________________________________
Parent/Guardian Address:
___________________________________________________________
Child Care Provider's Name:
___________________________________________________________
Business Address
___________________________________________________________
Registration Number:
_______________________ Telephone no. _______________________
No. of hours
Gross amount
Date placed
Amount of grant /
Name of child
usually in your
usually charged
in your care
value of vouchers
care (per week)
to parent/guardian
1) _______________
____/____/____ ____________ _______________
________________
2) _______________
____/____/____ ____________ _______________
________________
3) _______________
____/____/____ ____________ _______________
________________
School Holidays: If any of the above children are in your care for school holidays only, or for extra hours
during school holidays, please clarify:
Payments: Please list below the net amount (excluding vouchers / grant) actually charged to the
parent / guardian during the most recent 14 weeks of childcare.
Week Ending
Amount Charged
Week Ending
Amount Charged
Other Information: If the number of hours of any of the above children are with you alter on a regular
basis (other than during school holidays) please explain this:
Signed:
_________________________
Position:
________________________
Date:
_________________________
Please return the completed form by post to;
Or by hand to;
Benefits Section, Strategic Resources,
Customer Service Centre, Bayard Place
Town Hall, Bridge Street, PE1 1BF
Broadway (opposite Central Library)
PROOF OF CHILD
AB
CARE COSTS
Claim ref: __________________________
(To be completed by the child care provider)
Parent/Guardian Name(s):
___________________________________________________________
Parent/Guardian Address:
___________________________________________________________
Child Care Provider's Name:
___________________________________________________________
Business Address
___________________________________________________________
Registration Number:
_______________________ Telephone no. _______________________
No. of hours
Gross amount
Date placed
Amount of grant /
Name of child
usually in your
usually charged
in your care
value of vouchers
care (per week)
to parent/guardian
1) _______________
____/____/____ ____________ _______________
________________
2) _______________
____/____/____ ____________ _______________
________________
3) _______________
____/____/____ ____________ _______________
________________
School Holidays: If any of the above children are in your care for school holidays only, or for extra hours
during school holidays, please clarify:
Payments: Please list below the net amount (excluding vouchers / grant) actually charged to the
parent / guardian during the most recent 14 weeks of childcare.
Week Ending
Amount Charged
Week Ending
Amount Charged
Other Information: If the number of hours of any of the above children are with you alter on a regular
basis (other than during school holidays) please explain this:
Signed:
_________________________
Position:
________________________
Date:
_________________________
Please return the completed form by post to;
Or by hand to;
Benefits Section, Strategic Resources,
Customer Service Centre, Bayard Place
Town Hall, Bridge Street, PE1 1BF
Broadway (opposite Central Library)