CLAIM FOR REIMBURSEMENT OF CHILD CARE EXPENSES

TO	Joseph Crowe, Director Quality Career Services 2515 Wabash Avenue, Suite LL1 St. Paul, MN 55114 FAX: 651-647-0423 Office: 651-647-9322

Provider	Client’s Full Name
Address	Children Name(s)
City/Zip
Phone Number
License Number

Week #1

Date

Hours in care

# of children

Cost per day

*Other charges

Sub total

Week #2

Date	Hours in care	# of children	Cost per day	*Other charges	Sub total
				Total

*Other charges must be itemized on the back of this form.

Child care reimbursement is intended to cover the cost incurred while the parent is ATTENDING CLASSES ONLY.

Forms must be submitted AT LEAST ONCE PER MONTH.

Signature of Provider

Date