Case Name:

REQUEST FOR REIMBURSEMENT

I understand anCilagree to the following terms and conditions: Sign child(ren) in and out each day with the actual time and my flYlIsignatur.e. Gi\(e a full explanation of each chilo's absence to the pjrollider anElthe County. Bepoct to my ChilGlCare case manager changes in my need for child care services immediately or within 5 days. Report to my Child Care case manager changes affecting my eligibility for child care services immediately o~ within 5 days. Accept responsibility for any charges related tel unexcused absences of parenVresponsible adult or child(re ) and !Drovider fees not reimBursed by the County. Pay back Chil<llGare reimbursernent overpayments, even it it is' the CountY's fault. If I fail to eomply with any of the terms ana Gonditions for receipt of Child Care services, m ~hild Care sef'.(ices may be terminated, and am overpayment may exist, which I may be responsible to repay. Child care is only reimbursed for county approved activities.

pare~~o~j;

1~2~

~dU'Ad~ (;Jt;;G~Sib~~ult (fAd~

'"'

am~p~52J ,)!o:me Phone #

__ \

qcQ5'

I'Work Phone #

~:JJSt:g_oS Po
p"'eIlPh~#

Worle Phone #

Q_o'1fiJ.1 - 'CfQ.g

~~'l565-of1~
Birtt1date:

CHILD Name:

Did y,ou ha e a change of: Address, Employment, Heurs ef work, Welfare-to-Work hours of pa~I"1' Hours of Ghild Gare needed, lnccme, School schedule, Householtj cempositlon, Marital status? Yes __ No . If yes, explairr

.....,.

~o~

~~~

o tieclere

.....

under penalty 'Ofperjury under the laws of United'States and the state of California that the faots contained in this report are true, correct

Parent's:6Responsibl9' Adult's Signature: PRQVIDER: Name: Adlress:

e I.
.)
Days

I Date: I

. I(3!:L~,j2

'ne

.$ L 0'0

IE" wh,-kc;..ve A.v~

No
by the Provider)
Rate Charged

5hqbo

Is this a new address? Yes __ Phone Nlumber:

L.C1t yes, elate of address change:

~6;t/~

Ce~e$/

1/5'5 c:> ~
iiiiII :J.

AGENCY USE ONLY AG Initials: Service Month: Date:

PROVIDER CHARGES (Must, be completed Indicate Total Care."'Type FulllTrme Part Time Hours W!eks, Months

Sub-Total

t~ r-- '.l../
"

'7>)
Total Amount Charged

\q/6
$ )j<!O

Registration Fee + Less Family Fee

<z>'OtFSS Name: Date:

Total !Due From Agency ~

1tfec/illfe under penalty of perjury under tne laws of United States and the st-ate of California that (fie chilJ' care services stated in this form were given by me, received by the aBove mentioned child, and that any requiretf parental payment was paid. I understand that the County does net ac! as my employer er have a business relationship with me when I receive a child cere reimbursement. Family fee receipt of payment Is attached (if applicable).

Provider's Name: P.rrovider'sSignature':

I?.;>, \(k.C _sha.j,u

?'~

I Facility

Name

'(if a~plicable):

~~

I Date: J.llj/J~~J...

Dail" Attendance Silg'n-In Sheet for ttJ1e Month 01

Day,
M0 onth Tlrne inl awpm

A.1:lC}'~\
Pa<ent's full Signat.'e

CHILOYName
11\11 tjme fn
a""pm

;:s~~
-

I,a.-J<)Y\

"M.~"
full

t:.4~
Qocument Reasor.1s fciry'CJilildls Absenoe!;"

eGRRl.(i)8J~ 1 Total
ijOU~$'

IN
Parent'sJGuardian's f.1IJ Signature In lnlc

Schoo~liime In!Time Out

To school

' Ad'ditionalliirne 0utfrime

Time Oul arrvpm

OUl:
I Jlme out
l!.'IJiIPJT1] Parent's/Guardiah's Signat",e'i'll1~k

Provider's .. From
Initials school

Provider's Initials

Parent's full Signature,

~~en(fy lVse Orily

---~------------~--~----~l~:~ Ca.~
10
12 13 14

"

>--1"" __

It1...>

'l!,O

~
---:

~,~
_~ -----'

~
~

Ii ~
fi-.,.__"lIA __

It"'-....._....

Q
~

---------~ ~ ~ ~ ~

-"_

t-O..

--

I- --

./!I

~'

~!l
-/

21 k

'"

~-~-'
---...
/

23 ...... 25 ~

\]\

earefit/Provider Declaration: I declare under penalty of perjury: 1) tfie above information is true and correct, 2) that child care was used and provided while'the pareli1! or respons-iThleadult worked ol"garticipated in a County-approveo activity on the days and flours listed above, 3) I may be required to repay any overpayment resulting from false or incorrect claim forms and I may be prosecuted fort fraud if so determined, and 4) I understand that failing to report facts or giving wrong or inc::omplete facts on tl<1is regert carl result il1 disqt!Jalification trorn the program al'ldfor legal prosecloltio,nwith penalties of a fine, imprisonment Of both. _
Date:

Date:

Stanislaus (\;ounty Community Services Agency PG>Box 42, Modesto CA 95353-0042

\,
Month

/ cQ_o\j
Year

Case Name: Case Number:

AI ata {(a AJtl/f?1 '

,io <;? Cft/7'g

REQUEST FOR REIMBURSEMENT

Instructions: .
If you have approved child care costs and want a reimbursement, fill out and return this report to the StanWorks Child Care Proqrarn immediately following the last day care was provided . If a completed r,eperrtis not received timely, your reimbursement may be late, denied, or discontinued and payment may become the parent's responsibility. I understand and agree to the following terms and conditions: Sign child(ren) in and out.each day with the actual time and my full signature. Sive a full explanation of each child's absence to the provider and the County. Report to my Child Care case manager changes in my need for child care services immediately or within 5 days, Ref'lort to my Child Care case manager changes affecting my eligibility for child care services immediately or within 5 days. Accept responsibility for any charges related to unexcused absences of parenVresponsible adult or child(ren) and provider fees not reimbursed by the County. Pay back Child Care reimbursement overpayments, even if it is the County's fault. If I fail to comply wit any of the terms and conditions for receipt of Child Care services, my Child Care services ma ee terminated, and an overpayment may exist, which I may be responsible to repay. Child care is only reimbursed for county approved activities.
Adult (First, Middle, Last) WorK Phone #

RarentlRespensible ~.:i~ 2nap'ar:ntl'rspof~ibre

Ada-Y11
Adu~ (Flrs), Middle"Last) WorK Phone 11

~ell PhO~\!l' ,IJ

/V'aXCV(IGt

A~

Q_~.C( )505
Birthdate:

_CJ1/~

'JlJ!'1

CHILD Name:

Did YlU nave a change of: Aedress, Employment, Hours of work, Welfare-to-Work hears of pa~~on, Hours of Child Care needed, Income, School schedule, Household cernposltion, Marital status? Yes __ No . If yes, explain: -

..
-I

I declare under penalty of per:jury under the laws of United States and the state of California that the facts contained in this report are true, corr-ect and complete.

Rarent's/Responsible Adult's Signature: PROVIDER: NarTile:~o Address:

~~

Date:

/1 3 / j__ v t~ ..

n l (V\e "
oj

Ie u f (!2<J
Days

whJ=
No.cLIf
Rate Months Charged

~~

c,
AJe

A~ #~5 Ceres 7 cA
_
AGENCY USE ONLY AC Initials: Service Month: Date:

..

Is this a ew addfass? Yes __ Phone Number:

yes, date of address change:

q) '~_']

Yo-1...A-/'tJ
by the Provider)
Sub-Total

PROVIDER CHARGES (Must. be completed Indicate Total Care Type Fulll'ime Part Time Hours Weeks

'-5 ~ I{;,

qer
Total Amount Charged Registration Fee Less Family Fee Total Due From Agency

\ '~ 6f::.l
$ ~ 0 <:::> 1-----4
~
d-

I--~=---I

S:S trl:S

FSS Name:

Dale:

~--------------------------------~--------~
1 Jacility

I declare under penalty: of perjury under the laws of United SPates and the state of Califernia that the cliJilti care ser:vioes stated in this tonm were given b%me, r.eeeived by the eaov mentioned child, and that any required parental payment was paid. I uederstene that the COI9r:rty does net act as my employer or have a business relatienship with me when I receive a eNid care reimbursement. Family fee receipt of payment Is attached (if applicable).

Provider's Name: iProvider's Signature:

//_u {,~
-f"
nAI .

e qh erh,(J_j

Name

<.~applicable):
1

,.._

...lI.

Date:

...

Day M~~th Time in amlp'm

INI
RarenJl"'Gua(diag~sJfull Signature inlink

Sc!1ool'liinte
To school

Inmme Out
Provider's Initials 11me (j}uJ am/pm

~q(:J~ti0n~,tT~me 01!!.,tfFlp:l~Jln
Baren!'s fulliSignature Time. I.!) amlpm Parent's,full Signature

OW.
I
(f'ime out amlpm Ra,ent'slGua{dian',Sitiill Si!ll'ature in ink, IDocumeritD)'Ieasons lifor Cbiltfs,Al'lsences

lIolal
HOU[S

Provider's ,; From Initials l=schoot

.lI.Ql-em@y, lYse'''-

onJ~'

I~

...

3 4f--

"

'F!'

5r

I~

,till.

~
I~
,

~ ~l../,;:J;A"\

,'It

.
_;'

~..lIf~J
l....--"'1I\7~"'.j,}
j-"'::'{~
-""'-

.~

e \" ~

241~

25

26 rtl!t.~ 1f.C~ 2\1' \,,~?k ~ 22' 1.f:'<;~ ~_')

--;t;>

~_

1~&JJ1~ ts,~J-J
~
1'<; I

(~

--

29 \l'~1M. 7(Z~"J) 3'I!lY ~" ~

31

-ee-

"

..

Pal'entiProvi'der Declaration; I d"eElare under penally of perjurw 1) Hie abeve inlorrnatien is true and C0firect, 2) that child care was used an! proviillee wHile the pare."t or respeesible ac3liit;.wmked or I;lal'licipated in a @Qut:ltY,-apW0"'edactivity on the days and hours listed above, 3) I may be r,e~uified to regay amy Qverfilayment "esuINIil!:J from false or ineorreel Glaim forms and I may: be prosecl'Jled I(i)ft fLaue, if so determined, amd 4) I understand Hal failing to report facts or, i'iling wr(i)ng er incQJlllplet,efaets on this reporl can result in aisR,l!Iallficati(:Jn from the JilT0!!Jra!i!i) and/or legal [ilroseGlJtiQnwith penalties 01 a\ fine, imprisenment Oftbeth,
Providerr's 3i~fl<atiure:
I~

COMMUNITY

SERVICES AGENCY
Christine

C. Applegate

Director 251 E. Hackett Road P. O. Box 42, Modesto, CA 95353-0042 Child Care Information Une: 209.558.2332 Fax: 209.558.3730 case Name:

Na_/;cdr'a

~se#: District #:

10 g'q 'I ~'i'

case Manager:.Usa..!'1JI1U11'11

Employment Verification'
Dear
\.

CONGRATULATIONS!!! ou are working. You must provide verification of employment to this office by Y Please provide proof of emp.loyment by submitting all of last month's check stubs and this form completed by you and your employer. You must have your employer complete the form below. Please list your dally work schedule prior to h~ving your employer complete the form. If your schedule varies, list the last four (4) preceding week's schedule as a sample. Please remember to list AM or PM,_,Example- From: 2:30PM To 6:00 ~M. Eailure~to return the appropriate proof of employment by the DUE DATE may affect your benefits.' If you have any questions, please contact your Child care case Manager. . I authorize release of the information requested. ~ _ _.

's

re

1.

Employer Name:

Address:
2. Employee's Position: Job~ption: Employee's Start Date: If employee Is returning S. 6. 7. 8.

3.
4.

----~--------------------from a leave of absence, please Indicate return to work date:

~

Please check:

D Pennanent D Temporary D Seasonal

Employee's Hours Per Week Rate Qf Pay Paid (orde one): Tips? Yes No Weekly Effective Date of Rate of Pay Twice a Month Monthly Arst Pay Date: __ _

Bi-WeekJy

Tips/Month $

Employer's Signature

Job Title

Date

Phone #

Of saMCIS I'OIII'MIUES NoD CNI.DIIEIt INC.

~~~

STRIVING Page 1 of 1

TO BE THE BEST COUNTY IN A!.~ERICA

<# , ... ~

(04-2010) CCVOE

------

---

Big Lots Run Date: . Run Time: Eml2lo~ee: Pa~ Period: Date 11/13/11 11/20/11 06:21 Adam, Rony E For 11/13111 Thru 11/19111 Time Card Report Eml2lo~ee #: 0446301693 Bad2,e #: 0000007451 Ovtl .00 0.00 .00 0.00 .00 0.00 .00 .00 .00 0.00 .00 0.00 Ovt2 T-Hrs .00 4.00 0.00 .00 0.00 .00 0.00 .00 .00 .00 0.00 .00 0.00 5.00 MOO073 00000005 4.90 .50 2.60 MOO073 MOO073 MOO073 00000005 00000005 00000005 ?PIE ?POE PUNCH IN EA PUNCH OUT E 4.00 MOO073 00000005 4.00 MOO073 00000005 .Job Code MOO073 Pa~Rule: Status: Dept Code 00000005 02 PT Code Store Num: Page Num: Del2t: 00000005 Job: MOO073 Hours 0446 2

MERCH Store Assoc Messa2,e

~
REG

In 01:57C

Out 05:57 C

Re2, 4.00 4.00 4.00 4.00 4.00 4.00 4.90 .00 2.60 7.50 5.00 5.00

. Daily Totals 11114/11 REG 01 :57 C 06:00 C Daily Totals 11/15111 REG 01:57C 05:59 C

eo,.

Daily Totals 11/17/11 11/17111 11/17/11 REG LUN REG 03:58 C 08:55 C 08:55 C 09:25 C 09:25 C 11:58 C Daily Totals 11/19/11 REG 06:57 C 11:56 C

Daily Totals Regular Hours Overtime I Hours Overtime 2 Hours Total Hours ****Premium ****Exceptions Hours**** Hours**** 24.50 0.00 0.00 24.50

Associate Certification I certify that the above time records are complete and accurate. In addition, I certify that no one has instructed me to report inaccurately my hours worked, meal periods or absences from work. I understand that I must contact my manager if the above time record is inaccurate. I also understand that I must contact my District Manager or Regional Human Resources Manager if! have any unresolved questions or concerns.

AsGf2

l11Q.5!t~\\
Date

Big Lots -:-un Date: Run Time: Emulo~ee: Pa~ Period: Date 11127/11 12/04/11 06:13 Adam, Rony E For 11/27111 Thru 12/03111 Time Card Report Emulo~ee #: 0446301693 0000007451 Bad2e#: Re2 4.00 4.00 4.50 .00 3.00 7.50 4.80 .00 1.30 6.10 4.90 .00 3.10 8.00 4.90 .00 .60 5.50 Ovtl .00 0.00 .00 .00 .00 0.00 .00 .00 .00 0.00 .00 .00 .00 0.00 .00 .00 .00 0.00 Ovt2 T-Hrs 4.00 .00 0.00 .00 .00 .00 0.00 .00 .00 .00 0.00 .00 .00 .00 0.00 .00 .00 .00 0.00 4.90 .50 .60 MOO073 MOO073 MOO073 00000005 00000005 00000005 4.90 .50 3.10 MOO073 MOO073 MOO073 00000005 00000005 00000005 4.80 .50 1.30 MOO073 MOO073 MOO073 00000005 00000005 00000005 4.50 .50 3.00 MOO073 MOO073 MOO073 00000005 00000005 00000005 Job Code MOO073 Pa~Rule: Status: Dept Code 00000005 02 PT Code Store Num: Page Num: DeUt: 00000005 Job: MOO073 Hours 0446: 2

MERCH StoreAssoc Message

REG

In 01:57C

Out 06:00C

" Daily Totals 11/28/11 11/28/11 11128/11

REG
LUN

REG

07:57 C "12:31 C 12:31 C 13:01 C 13:01 C 16:05 C Daily Totals

MAN

MANUALEDr

11/29/11 11/29111 11/29111

REG
LUN

REG

01 :57 C 06:46 C 06:46 C 07:16C 07:16C 08:37 C Daily Totals

?POL

PUNCHEDOU

12/01111 12/01/11 12/01111

REG
LUN

REG

06:57 C 11:55 C 11:55 C 12:25 C 12:25 C 15:30C Daily Totals

12/03/11 12/03/11 12/03/11

REG
LUN

REG

06:00 C 10:56 C 11:26C

10:56C 11:26 C 12:04C

Daily Totals Regular Hours Overtime I Hours Overtime 2 Hours Total Hours ****Premium ****Exceptions Hours**** Hours**** 31.10 0.00 0.00 31.10

Associate Certification I certify that the above time records are complete and accurate. In addition, I certify that no one has instructed me to report inaccurately my hours worked, meal periods or absences from work. I understand that I must contact my manager if the above time record is inaccurate. I also understand that I must contact my District Manager or Regional Human Resources Manager if I have any unresolved questions or concerns.

ASSO~

Date

Big Lots Run Date: Run Time: Em(!loyee: Pay Period: Date 11/06/11 11/06/11 11106111 11113111 06:16 Adam, Rony E For 11/06/11 Thru 11112/11 ~ REG LUN REG In Out 01 :57 C 06:55 C 06:55 C 07:25 C 07:25 C 09:29 C Daily Totals 11/07111 REG 01 :58 C 06:58 C Daily Totals 11/10111 11110/11 1111011 I REG LUN REG 01 :58 C 06:29 C 06:29 C 06:59 C 06:59 C 09:59 C Daily Totals Regular Hours Overtime 1 Hours Overtime 2 Hours Total Hours ****Premium ****Exceptions Hours**** Hours**** 19.50 0.00 0.00 19.50 Reg 4.90 .00 2.10 7.00 5.00 5.00 4.50 .00 3.00 7.50 Ovtl .00 .00 .00 0.00 .00 0.00 .00 .00 .00 0.00 Time Card Report Em(!loyee #: 0446301693 0000007451 Bad2e #:
.Joh

Store Num: Page Num: PayRule: Status: Dept Code 00000005 00000005 00000005 02 PT Code Dept: Job: 00000005 MOOO73 Hours

0446 2

MERCH StoreAssoc Messa2e

Ovt2 T-Hrs 4.90 .00 .50 .00 .00 2.10 0.00 .00 0.00 .00 .00 .00 0.00 4.50 .50 3.00 5.00

Code MOO073 MOO073 MOO073

MOO073

00000005

MOO073 MOO073 MOO073

00000005 00000005 00000005

Associate Certification I certify that the above time records are complete and accurate. In addition, I certify that no one has instructed me to report inaccurately my hours worked, meal periods or absences from work. I understand that I must contact my manager if the above time record is inaccurate. I also understand that I must contact my District Manager or Regional Human Resources Manager if I have any unresolved questions or concerns.

cfi;td
Associate Signature

Date

t \/~s;l20 I )

~
Big Lots Run Date: Run Time: Emnlo~ee: Pa~ Period: Date 12/04111 12/04/11 12/04111 12/11/11 06:16 Adam, Rony E For 12/04/11 Thru 12/10111 Time Card Report Emnlo~ee #: 0446301693 0000007451 Bad2e #: Ovt2 T-Hrs .00 4.90 .00 .50 .00 .60 0.00 .00 0.00 .00 0.00 .00 0.00 .00 0.00 5.00 MOO073 00000005 5.00 MOO073 00000005 4.00 MOO073 00000005 4.20 MOO073 00000005 ?POL PUNCHED OU' Job Code MOO073 MOO073 MOO073 Pa~Rule: Status: Dept Code 00000005 00000005 00000005 02 PT Code Dent: Job: Store Num: Page Num: 00000005 MOO073 0446: 2

MERCH StoreAssoc Message

REG
LUN

REG

In Out 01:57 C 06:54 C 06:54 C 07:24 C 07~24 C 08:04 C Daily Totals

".

Re2 Ovtl 4.90 .00 .00 .00 .60 .00 5.50 4.20 4.20 4.00 4.00 5.00 5.00 5.00 5.00 0.00 .00 0.00 .00 0.00 .00 0.00 .00 0.00

Hours

12/05/11

REG

01:57C

06:13C

Daily Totals 12/06111

REG

01:57C

05:58C

Daily Totals 12/07/11

REG

09:57 C

14:56C

Daily Totals 12/08111

REG

04:58 C 09:57 C Daily Totals

Regular Hours Overtime 1 Hours Overtime 2 Hours Total Hours "''''*'''Premium Hours"'*** ****Exceptions Hours****

23.70 0.00 0.00 23.70

Associate Certification I certify that the above time records are complete and accurate. In addition, I certify that no one has instructed me to report inaccurately my hours worked, meal periods or absences from work. I understand that I must contact my manager if the above time record is inaccurate. I also understand that I must contact my District Manager or Regional Human Resources Manager if! have any unresolved questions or concerns.

Date