CCP 2145 at a glance
What it is: CCP 2145 is the CalWORKs Child Care Reimbursement Report.
Who signs: At Signature of Parent and Date, the parent declares under penalty of perjury under the laws of the State of California that the information contained on this report is true and correct. At Signature of Provider and Date, the provider declares under penalty of perjury under the laws of the State of California that the information contained on this report is true and correct.
A filled-in CCP 2145 example: a parent fills out Part A for one child
How to fill out CCP 2145, box by box
Month/Year of Authorized Services
Enter the Month/Year of Authorized Services.
Parent(s) Information: Parent #1, Parent #2 (If in the home) and address
Under 1. Parent(s) Information, enter Parent #1 Name (First, Middle, Last), Case Number and Phone, then Parent #2 (If in the home) Name (First, Middle, Last) and Phone, then the Address (Street, City, State, Zip Code) and Work Phone (If Applicable).
Child Information
Under 2. Child Information, enter the Child's Name, Birthdate and Age.
County Use Only
COUNTY USE ONLY: Date Received: Case Name:
Certification
I have the right to choose the child care provider who is best for me and my child.
The provider must have a license or be exempt from having a license in order to receive a child care payment.
I must pay back any child care payments I am not entitled to receive.
Provider's Name and addresses
PART B - ONLY CHILD CARE PROVIDER FILLS IN THIS SECTION.
Under 1., enter the Provider's Name (First, Middle, Last) Or Name Of Facility, the Address Where Care Is Provided (Number, Street, City, State, Zip Code) and Phone. Check here if new address.
Enter the Billing Address If Different From the Address Where Care Is Provided (Number, Street, City, State, Zip Code) and Phone. Check here if new address.
Child Care Provider Billing Summary
Under 2. Child Care Provider Billing Summary (I provided Child Care for the child listed on the front), enter the Monthly Rate / Month, the Weekly Rate X Week(s) =, and the Daily Rate X Day(s) =.
Enter the Hourly Rate X Hours =, the Evening Rate X =, the Weekend Rate X = and Other Fees.
Enter the TOTAL BILLED FOR THIS MONTH: and Other Information:
Signature of Provider
I understand that if I am a license-exempt provider, a payment may not be paid if not cleared through the Guardian background check process unless I am an aunt, uncle, or grandparent of a child in my care.
I understand that I must charge the same or lower rate for the participant's child listed on the front as I would charge other clients for the same service.
I understand that failing to report facts or giving wrong or incomplete facts on this report may result in legal prosecution with penalties.
Attendance Time-In and Time-Out
PART B, must be completed by the child care provider. The center Time-out and Time-in section of this attendance form must be completed ONLY for the child enrolled and attending school or the child on a split schedule.
Enter the Child's Name, Case Number and Month/Year of Request.
Daily Sign In Use Only If Child Has A Split Schedule (i.e., for School Schedule) Daily Sign Out. Day of Month - Enter Day of Week.
Total Hours of Care for the Month
Enter the Total Hours of Care for the Month.
Common questions about CCP 2145
Where do I file it?
Please fill out and return this form to your child care worker each month for child care reimbursement. This form must be signed and dated by both the parent and child care provider on or after the last day of care. One form per child must be submitted to request reimbursement. If needed, ask your county worker for more copies.
When is this form not the right one?
If the provider listed in Part B, on the next page, is NOT your current provider, do not use this form. Contact your worker immediately.
Sources
[1] CalWORKs Child Care Reimbursement Report (CCP 2145) (7/23), California Department of Social Services (the Official source link on this page).