Fillable Please complete this questionnaire with your child care (County of Erie, New York)

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Please complete this questionnaire with your child care (County of Erie, New York)

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U.S.A. forms for County of Erie, New York

BROWSE COUNTY OF ERIE, NEW YORK (NY) FORMS

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95 FRANKLIN STREET – BUFFALO, NEW YORK 14202
Child Care Payment Questionnaire
Department of Social Services
Division of Family Independence | CED & TA
B-3923(3/2018)
First Name
M.I.
Last Name
Case Number
Address
City
Zip Code
Please complete this questionnaire with your child care provider and return it to the worker
listed below. A separate questionnaire is required for each child care provider. A new
questionnaire must be completed:
with each Certification and Recertification
if there is a change in child care providers
if there is a change in your hours of employment
if there is a change in your household composition
if there is a change in the cost of your child care
TO BE COMPLETED BY CENTER/PROVIDER
DBA Name
Provider SSN
OR
DBA TAX ID
- -
-
Address Where Care is Provided
City
Zip Code
Mailing Address
City
Zip Code
Contact Person
Telephone Number
License #
License Period
to
CCFS ID #
Expiration Date
Vendor #
Are you in Receipt of Temporary Assistance
TA Case #, if applicable
Yes
No
Please indicate if your business can be categorized as being owned by any of the following
AA-Asian American Black Hispanic AI-Native American WO-Woman Owned Veteran Owned
Type of Child care
Day Care Center
Group Family Day Care Provider
Family Day Care Provider
School Age Child Care Program
Legally Exempt Relative in Parent’s Home
Legally Exempt Non-Relative In Parent’s Home
Legally Exempt Relative in Relative's Home
Legally Exempt Non-Relative in Non-Relative's Home
Date
RETURN TO:
Caseworker/Examiner
Unit/Worker#
Phone #
95 FRANKLIN STREET – BUFFALO, NEW YORK 14202
NOTE: Payments will be based on the actual number of hours employed, plus a reasonable travel time allowance.
THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Client Signature
Date
Provider Signature
Date
PARENT - Complete
Place of Employment/Training
Mode of transportation
Car Public transportation Other (specify):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Daily Work/Training Schedule
(e.g. 9am-5pm)
Travel time from child care provider to work/approved activity (e.g. 25 minutes):
Travel time from work/approved activity to child care provider (e.g. 25 minutes):
PROVIDER – Complete for each child in care
Child 1
Child 2
Child 3
Child 4
Child 5
Child's Name
Child’s DOB
Name of child’s school
Child’s School schedule
(e.g. 9:00 am – 3:55 pm)
Date child started in care
Hours in care per day
Days in care per week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hourly cost of child care
Part day cost of child care
Daily cost of child care
Weekly cost of child care
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Completed 25 January 2021

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