Form Dshs 18 607 – Fill Out and Use This PDF

STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES

DIVISION OF CHILD SUPPORT (DCS)

Child Care Verification

TO:	CASE NUMBER:

The Division of Child Support (DCS) needs verification of your child care expenses for the period.

Please have your child care provider complete a separate Child Care Verification Response (page 2 of this form) for each child listed below. Then you must date and sign each response form, attach proof of payment for the care provided, and return it to DCS at the address listed below. Proof of payment may be receipts or copies of cancelled checks. Return

the completed form(s) no later than	.
Children's Names

DATE	AUTHORIZED REPRESENTATIVE
	DIVISION OF CHILD SUPPORT

Return the completed response form(s) to:

DIVISION OF CHILD SUPPORT

PO BOX 11520
TACOMA WA 98411-5520
Within		calling area
Outside		calling area

TTY/TDD services available for the speech or hearing impaired.

Visit our web site at: www.dshs.wa.gov/dcs

No person because of race, color, national origin, creed, religion, sex, age, or disability, shall be discriminated against in employment, services, or any aspect of the program's activities. This form is available in alternative formats upon request.

FG VER: (1.5)

	CHILD CARE VERIFICATION	Page 1
	DSHS 18-607 (REV. 09/2011)

STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES

DIVISION OF CHILD SUPPORT (DCS)

Child Care Verification Response

Complete a separate form for each child listed on page 1.

DCS Case Number

Child Care Provider Name and Address

Child Care Provider Telephone Number (include area code) (						)
Child's Name
I am paid $				per		for this child. Of this amount, I receive
$			subsidy from Washington State or another state or government agency per month for this child.

Enter the amounts you received from the custodian that Washington State or any other state or government agency did not subsidize. This page has space for 12 months of payments. Attach additional sheets if needed.

Amount	Period (month/year)	Amount	Period (month/year)
$			$
$			$
$			$
$			$
$			$
$			$

I declare under penalty of perjury, under the laws of the state of Washington, that the foregoing is true and correct. I understand that DCS will use the information I have provided for child support purposes and will become public record. DCS may disclose the information to the noncustodial parent upon written request to DCS and pursuant to public disclosure policy.

Date	Child Care Provider Signature
Date	Parent / Custodian Signature

FG VER: (1.5)

	CHILD CARE VERIFICATION	Page 2
	DSHS 18-607 (REV. 09/2011)