Benefits Service
Wealden District Council
Council Offices, Vicarage Lane
Hailsham, East Sussex
BN27 2AX
Telephone; (01323) 443500
hone number
Proof of Child Care Form
Child care cost details to be completed by the child care provider.
Please complete one form per child
Childs full name
Name, address and
telephone number o
f the
registered nursery,
childminder or playscheme
What is your Child Care Registration number?
How much per week is charged during term time (after funding/deductions)?
How m
any term time weeks per year do you provide care?
h per week is charged during school holidays (after funding/deductions)?
How many school holiday weeks per year do you provide care?
Email Address
Benefit reference number
Please use this space to tell us of any period/s when child care costs are not
charged or are increased, or any other information you think we need.
Your Signature
Please sign below to confirm that you have read and understand the declaration above:
Click Here to print form to sign and send to us
This information can be made available in large print, braille, audio/CD or in another language upon
Please telephone: 01323 443500 Email:
Please read this declaration carefully.
• As far as I know, the information I have given on this form is correct and complete
• You may make any necessary enquiries to check the information on this form
• You may cross check the information I have given with other services in the council, other council
or benefit authorities, including HMRC.
• I understand that if I give information that is incorrect or incomplete or fail to report any changes
which might affect my benefit, I may be prosecuted.
We will keep this information confidential, but if you fall behind with your rent or council tax
payments, our Recovery Officers may need to read this form so that he or she can help you.