Form Dshs 18 607 PDF Details

DsHS 18-607 provides specific instructions for the completion of the Determination of Medically Handicapped Children form, also referred to as Form 607. The instructions are outlined in a clear and concise manner, making it easy for anyone to understand. In addition, important information is included regarding what is required to complete the form accurately. This ensures that all pertinent data is collected and that no mistakes are made when submitting the form. If you have any questions about completing this form, be sure to consult with your healthcare provider or local Dshs office.

QuestionAnswer
Form NameForm Dshs 18 607
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesverification, subsidy, care, dshs 18 607 child care verification

Form Preview Example

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)