ATTENDANCE SHEET

Provider: Month/Year: May 2015 Program: 64 C3AP

bAb/¸ twh±L59w Child Name: WOIbb¸ /IL[5прр /I¦w/I {¢Φ Child DOB: 08/13/2006, 8 - 8

SAN FRANCISCO, CA 941мн-1ноп Parent Name: W!b9 t!w9b¢ (1202)

Specialist: Ana User

ATTENDANCE MUST BE COMPLETED DAILY

FAMILY FEE CERTIFICATION & RECEIPT PART TIME FEE: $115.00

(Please Check One Box)

oAll Family Fees have been paid. Amount Collected: $______________ Provider Initial:_____________

o Family Fees have not been paid and I do not have a payment plan in place. Outstanding Balance : $___________ Provider Initial:_____________

oA Payment Plan is in place between the parent and the provider. Amount Collected: $______________ Provider Initial:_____________

PARENT Self-Certification PROVIDER Self-Certification

As a parent, I declare under penalty of perjury that the information above is an

accurate record of child care provided and that during this time period I was

employed, or attending training/school, or other qualifying activity.

As the provider, I declare under penalty of perjury that the information above is

true and correct, and that the child care as stated above was provided. I

understand that I may be required to repay any overpayment.

Parent/Guardian Signature: Date: Provider Signature: Date:

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