FAMILIES

Provider Transfer Attestation — Current Provider

Current-provider-completed portion of the ELCHC Provider Transfer Form (Rev. 2/8/18).

This form is completed by the parent's current child care provider to confirm the parent has satisfactorily fulfilled their copayment obligation. Please match the parent and child below to the transfer request on file.

Transfer Request Details

Parent/Guardian Name(Required)
Child(ren) Being Transferred
Name of Child
Child's Date of Birth
 

Current Provider Information

Address

The provider is responsible for collecting the parent co-payment from the parents. The parent co-payment shall be collected within 10 calendar days of the provider's payment due date. The provider shall provide written notice of the co-payment due date and the provider must give the parent a receipt for each co-payment made by the parent and retain receipt records for all child care co-payments. (Rule 6M-4.400, F.A.C.)