Form Ccp 2145 – Fill Out and Use This PDF

The CCP 2145 form, or Sacramento County Stage One Child Care - Request for Reimbursement Form, is a document designed for caregivers and parents to document and request reimbursement for child care services provided. It mandates meticulous record-keeping including sign-in and sign-out times, adherence to using specific ink colors, and dual signatures to ensure accuracy and integrity in the billing and reimbursement process. For those in Sacramento County seeking to navigate the process of child care reimbursement, comprehending and completing this form correctly is a crucial step. Click the button below to begin filling out your form properly.

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Form Ccp 2145 PDF Details

Ensuring the safety, well-being, and proper care of children while their parents are at work or engaged in other necessary activities is a priority that governs the design and implementation of child care reimbursement systems such as that specified by the CCP 2145 form in Sacramento County. This particular form stands as a vital document for parents and child care providers alike, facilitating a structured request for reimbursement for child care services rendered. Detailed in its design, the form requires precise entry of daily sign-in and -out times by parents, using either an initial or full signature, without the use of white-out for corrections, and insistence on completing the form in either blue or black ink. It goes further to mandate that both sides of the form are filled out and bear the signatures and dates of both the provider and the parent, post the last day of care within the month of service. This exhaustive documentation process ensures that reimbursement requests are accurately reflected and timely processed, albeit with a stringent deadline that requests must meet, typically within three months post service, to warrant payment. Moreover, the form is scrupulously structured to capture detailed child and parent information, alongside specifying billing summary requirements on the provider's end—articulating all service rates and total billed amount for clear, transparent communication. Crucially, the form also contains provisions for the inclusion of specific codes corresponding to situations where care is not utilized as planned, thereby illustrating its comprehensive nature in addressing all potential scenarios faced by families and providers in the dynamic context of child care service delivery.

Question	Answer
Form Name	Form Ccp 2145
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	California, CCP, CCPU, ccp 2145 form

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Sacramento County Stage One Child Care - Request for Reimbursement 2145 Form

COMPLETE AND MAIL THIS FORM TO: DHA, 2001 19th Street, Sacramento, CA 95818

Month/Year of Care

•Sign child in and out of care daily using your first initial and last name OR full signature. Only enter in and out times for the hours of care child actually uses.

•Do not use “white-out”. Days marked with “white-out” will not be paid. Complete this form in blue or black ink only.

•Both sides must be complete, and the front must be signed and dated by both the provider and the parent on or after the last day of care. All forms must be

received no later than 3 months after care took place for payment to be made. If this form is received late or incomplete, payment will be denied.

•Check that all hours/days/weeks entered in Section 4 - Billing Summary below matches the hours/days/weeks of care used on the back.

•Each day the child does not use care as scheduled and payment is expected, enter one of these codes in the “Reason Code” box on the reverse:

Child or parent ill & child was not

Provider closed all or part of

Child absent for other

School-age child did not attend school

School Minimum Day

Non-School Day

in care all or part of day

the day

reasons

due to illness but was in care

SECTION 1 AND 2 TO BE COMPLETED BY PARENT ONLY

COUNTY USE

SECTION 1 - Parent Information

SECTION 2 - Child Information

ONLY

Parent 1 Name:

Child's Full

FID:

Activity Type:

Employment

School

CWEX

Job Club

Name:

CID:

Activity Name:

Child's Home

PID:

Address:

Activity Address:

TID:

City, State & Zip:

County Date Stamp:

Activity Schedule

Phone:

(indicate days & times):

Date of Birth:

Age:

Parent 2 Name (if in the home):

Check here if not in the home

School

Name:

Activity Type:

Employment

School

CWEX

Job Club

Track:

Grade:

Activity Name:

Case #:

Activity Address:

Travel time from home to activity is

City, State & Zip:

Activity Schedule

minutes each way.

CCPU HSS:

(indicate days & times):

SECTION 3 AND 4 TO BE COMPLETED BY PROVIDER ONLY

SECTION 3 - Child Care Provider Information

SECTION 4 - Child Care Provider Billing Summary

Enter all numbers as decimals. If completed electronically, the worksheet will calculate as currency &

Type of

Licensed Family Child Care Home

compute a Total Billed amount at the bottom. If completed by hand, calculate totals in currency, add up

Facility:

all amounts entered, and enter a total in the Total Billed section at the bottom. For Evening & Weekend

Child Care Center

Trustline Provider

Rates, enter a unit type in the empty box, i.e. hours, days, etc.

ONLY ENTER AMOUNTS YOU ARE ACTUALLY BILLING.

Relative - Circle relationship to child: Aunt

Uncle Grandparent

Monthly Rate:

Month =

$0.00

(Must be by blood, marriage or legal decree, and verifiable. All other relationships, check Trustline Provider)

Provider Name:

Weekly Rate: $

Weeks =

$0.00

Weekly Rate: $

Weeks =

$0.00

Weekly Rate: $

Weeks =

$0.00

Doing Business

As (DBA) Name:

Weekly Rate: $

Weeks =

$0.00

Last four digits of provider's

Daily Rate: $

Days =

$0.00

SSN or Tax ID if incorporated:

Daily Rate: $

Days =

$0.00

Address Where Care is Provided:

Check here if new address

Hourly Rate: $

Hours =

$0.00

Hourly Rate: $

Hours =

$0.00

City, State & Zip:

Evening Rate:

$0.00

Provider's Billing Address:

Check here if new address

Weekend Rate:

Registration Fee due for licensed providers as per rate sheet:

City, State & Zip:

Month Annual Registration Fee is due as per rate sheet:

Phone Number:

TOTAL BILLED FOR THIS MONTH:

$0.00

By signing, we declare under penalty of perjury under the laws of the United States and State of California that the information I provided on the front and back of this form are

true, correct, and complete for the entire month. Any fraud of government funds will result in criminal prosecution to the full extent of the law.

______________________________________________	______________	_____________________________________	_______________
Parent Signature	Date	Provider Signature	Date

CCP 2145 (10/14)

Child's First and Last Name:		Month/Year:		COMPLETE IN HOURS & MINUTES ONLY

Start on the 1st day of care in the month. Fill in time child was dropped off & picked up, & sign on each day care took place.

*By initialing and/or signing this form each day, you declare under penalty of perjury under the laws of the United States and the State of California that the facts each

day are true, correct, and complete. Any fraud of government funds will result in criminal prosecution to the full extent of the law.

Dayof Week Date

AM or PM

in child

Out

Use ONLY if child

Initials*

AM or PM

out child

ReasonCode

COUNTY USEONLY

Initials*

has split schedule

Sign Out DAILY

Total

Time In

Signature* of adult signing

Time

Time Out

Signature* of adult signing

Hours

Circle

CCP 2145 (10/14)

TOTAL HOURS OF CARE FOR THE MONTH:

How to Edit Form Ccp 2145 Online for Free

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Step 1: Firstly, access the tool by clicking the "Get Form Button" at the top of this site.

Step 2: As soon as you start the online editor, you'll see the form prepared to be filled out. Besides filling in various blanks, you might also perform other actions with the form, particularly writing any words, editing the initial text, inserting images, signing the form, and much more.

This PDF form will need some specific information; to ensure accuracy and reliability, please make sure to take note of the recommendations just below:

1. You need to fill out the PID accurately, thus be attentive when filling in the parts containing all of these blank fields:

2. Once your current task is complete, take the next step – fill out all of these fields - SECTION Parent Information, Check here if not in the home, Employment, School, CWEX, Job Club, Activity Type Activity Name, Activity Address, City State Zip, Activity Schedule indicate days, Childs Full Name Childs Home, Grade Case, Travel time from home to activity, minutes each way, and CCPU HSS with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

3. This third section should also be fairly simple, City State Zip Providers Billing, City State Zip Phone Number, Check here if new address, Weekend Rate, X X X X X X X X X X, Registration Fee due for licensed, Month Annual Registration Fee is, TOTAL BILLED FOR THIS MONTH, By signing we declare under, true correct and complete for the, Parent Signature, Date, Provider Signature, Date, and CCP - all of these blanks will need to be filled out here.

People who use this PDF generally make some errors when filling out Check here if new address in this part. Be sure you read again whatever you enter right here.

4. You're ready to complete this next part! In this case you'll get all these Childs First and Last Name, MonthYear, COMPLETE IN HOURS MINUTES ONLY, Start on the st day of care in the, By initialing andor signing this, day are true correct and complete, Sign In DAILY, Use ONLY if child has split, Sign Out DAILY, D a t e, W e e k, D a y o f, Time In, Circle, and AM or PM fields to do.

Circle, day are true correct and complete, and By initialing andor signing this inside Trustline

5. Finally, the following final section is precisely what you will need to finish prior to submitting the form. The fields under consideration are the next: AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, AM PM, and AM PM.

Find out how to prepare Trustline stage 5

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Form Ccp 2145 – Fill Out and Use This PDF

Form Ccp 2145 PDF Details

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