CHILDREN’S DIVISION CHILD CARE PROVIDER CLAIMS COVER SHEET
This cover sheet is to be used by Child Care Provider Relations Unit (CCPRU) staff to document child care provider claims. This cover sheet must be placed in the provider’s file with all supporting documentation.
Child Care Provider Name	DVN
Child Care Provider Address	Provider County
City	STATE	Zip Code
Referral Source	Cause	Overpayment Total Amount
Claim Period
Begin Date (Month Year) /	End Date (month/year) /
Fund Code	Amount Overpaid	Service Month/Year	Child DCN	Child Name
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Provider Referred to SOT? YES NO	Provider Referred to Attendance and Payment Accuracy Training? YES NO
Provider Referred to WIU? YES NO	Provider Reviewed By CCRT? YES NO
COMMENT:
CCPRU Supervisor Signature	Approval Date
Assigned CCPRU Staff
Date of Discovery	Data Entry Date	Data Entry Person

CD-171 (08/12)