Fillable DEPENDENT CARE COST AFFIDAVIT (California)

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DEPENDENT CARE COST AFFIDAVIT (California)

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SIGNATURE
DATE
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DEPENDENT CARE COST AFFIDAVIT
I, , residing at
(PRINT NAME) (ADDRESS)
pay for dependent care.
(NAME OF AGENCY, INSTITUTION, INDIVIDUAL PROVIDER)
I am currently receiving assistance from to help me pay for
my dependent care costs.
(DEPENDENT CARE SUBSIDY PROGRAM)
My household’s total billed dependent care cost is $ per month.
I pay $ out-of-pocket for dependent care per month.
I declare under penalty of perjury under the laws of the State of California that the information provided
in this affidavit is true, correct, and complete to the best of my knowledge.
(Fill out completely before signing.)
CF 10 (12/13) RECOMMENDED FORM
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DEPENDENT CARE COST AFFIDAVIT (California)

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Completed 30 March 2022

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