The "Revised" Child Care and Development Fund (CCDF) Discrepancy Childcare Statement of Services, effective from July 1, 2005, serves as a crucial document for childcare providers and parents or guardians in the United States. This form meticulously records weeks of service, capturing details from the start date to the end date. Essential information such as provider identification numbers (EIN/SSN), names, addresses, and phone numbers for both childcare providers and parents or guardians are prominently featured to ensure comprehensive documentation and accountability. Significantly, the form delves into the specifics of any discrepancy that may arise during the provision of services, including card issues or problems with the Point of Service (POS) systems not being installed or malfunctioning. Daily attendance is logged with precision, noting times in and out, thereby calculating total hours and the amount owed for the service provided. The form further enhances credibility and legal accountability through the requirement of signatures from both the parent or guardian and the provider, with an insistence on signing in blue ink. This measure underscores the form's role in maintaining an accurate and verifiable record of childcare services, a safeguard against potential discrepancies or claims of fraud. The stipulation to keep a copy of the statement at the childcare center, combined with the coding system for days not attended, ensures a high standard of record-keeping and transparency. Additionally, the provision for mailing completed forms to the ACS-Statewide Discrepancy Department in Indianapolis, Indiana, facilitates centralized monitoring and resolution of service discrepancies, highlighting the form's integral role in managing childcare services within a regulated framework.
Question | Answer |
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Form Name | Ccdf Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | ccdf form printable, ccdf discrepancy, ccdf form download, how to ccdf form |
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"Revised" CCDF Discrepancy Childcare Statement of Services Form |
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7/1/2005 |
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Weeks of Service _______________ through ________________. |
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(Beginning) |
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(Ending) |
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Provider EIN/SSN: |
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Childcare Provider Name: |
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Parent/Guardian Name: |
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Childcare Provider Address: |
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Parent/Guardian Address: |
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City State Zip: |
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City State Zip: |
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Childcare Director's Name: |
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Provider Phone Number |
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Parent Phone Number: |
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Provider County Location |
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Child's Name: |
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One Child Per Form |
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Description of Discrepancy: |
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Card Issues |
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POS Not Installed |
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POS Not Working |
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Week 1 |
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Day |
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Date |
Code |
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Time IN |
Time OUT |
Time IN |
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Time OUT |
Total Hours |
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a.m. |
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a.m. |
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a.m. |
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Sunday |
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p.m. |
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p.m. |
p.m. |
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p.m. |
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a.m. |
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a.m. |
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a.m. |
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Monday |
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p.m. |
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p.m. |
p.m. |
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p.m. |
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a.m. |
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a.m. |
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a.m. |
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Tuesday |
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p.m. |
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p.m. |
p.m. |
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p.m. |
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a.m. |
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a.m. |
a.m. |
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a.m. |
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Wednesday |
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p.m. |
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p.m. |
p.m. |
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p.m. |
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a.m. |
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a.m. |
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a.m. |
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Thursday |
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p.m. |
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p.m. |
p.m. |
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p.m. |
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a.m. |
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a.m. |
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a.m. |
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Friday |
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p.m. |
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p.m. |
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p.m. |
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a.m. |
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a.m. |
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a.m. |
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Saturday |
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p.m. |
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p.m. |
p.m. |
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Totals |
Number of Days: |
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Amount Owed $ |
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Hours |
Week 2 |
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Day |
Date |
Code |
Time IN |
Time OUT |
Time IN |
Time OUT |
Total Hours |
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a.m. |
a.m. |
a.m. |
a.m. |
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Sunday |
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p.m. |
p.m. |
p.m. |
p.m. |
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a.m. |
a.m. |
a.m. |
a.m. |
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Monday |
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p.m. |
p.m. |
p.m. |
p.m. |
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a.m. |
a.m. |
a.m. |
a.m. |
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Tuesday |
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p.m. |
p.m. |
p.m. |
p.m. |
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a.m. |
a.m. |
a.m. |
a.m. |
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Wednesday |
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p.m. |
p.m. |
p.m. |
p.m. |
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a.m. |
a.m. |
a.m. |
a.m. |
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Thursday |
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p.m. |
p.m. |
p.m. |
p.m. |
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a.m. |
a.m. |
a.m. |
a.m. |
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Friday |
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p.m. |
p.m. |
p.m. |
p.m. |
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a.m. |
a.m. |
a.m. |
a.m. |
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Saturday |
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p.m. |
p.m. |
p.m. |
p.m. |
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Totals |
Number of Days: |
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Amount Owed $ |
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Hours |
I certify that this statement of services provided was provided to me by this provider. I further certify that this is an accurate and true record of attendance and can be prosecuted for fraud if this is a false statement.
Parent/Guardian Signature |
Date |
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Provider Signature |
Date |
SIGN IN BLUE INK
Maintain a copy of this statement onsite at the childcare center for each child.
CODES: |
P=Personal Day |
H=Provider Holiday O=Other _____________ (specify) |
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Mail to: |
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101 West Ohio Street, Suite #1700 |
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Indianapolis, Indiana 46204 |