3 Day Non-Payment Form

The policy and procedure below is based on Child Care Services Provider Manual, Chapter 8 Collecting Fees and Subsidies

Collecting Parent Share of Cost

Providers must collect fees in advance of care. Providers keep the fees they collect, and the amount of the assessed parent fee is deducted from the Child Care Service reimbursement to the provider.
Providers may collect parent share of cost:

Once a week
Once a month, or
On a schedule that meets the parent’s needs, as long as collection is documented and the fee is collected before child care services are provided.

When Parents Do Not Pay Their Share of Cost

Child Care Services will reimburse the provider the full amount of the fee or subsidy when providers notify Child Care Services on the third day of non-payment of fees or subsidies. If providers do not notify Child Care Services that a parent has not paid their share of cost or subsidy on the third day of non-payment, Child Care Services will not reimburse providers for the parent share of cost or subsidy.

Provider Information

Provider Name:	A value is required.
Provider Phone Number:	A value is required.
The following information is being submitted by:	A value is required.

Case Information

Parent/Guardian Name:	A value is required.
Case#	A value is required.
Monthly fee as stated on the most recent Form 2450 Authorization for Child Care:	A value is required.
Today’s Date: 07/29/2010

Date of last payment

Date 1:

*Amount paid: A value is required.

Comment: