New Hampshire Daycare and Child Care Forms

Effective Date Title – Owner – Description 01/08/2010

Preventive and Protective Child Care Invoice (Form 2501) – Child Development Bureau – Invoice submitted by child care providers to receive payment for providing care to children for preventive and protective child care services 01/04/2010

Criminal History Record Check Form and Renewal Form (Form 2602 and 2603) – Child Development Bureau – Criminal History Record Check Form and Renewal Form 08/03/2009

Licensed Child Care Provider Agreement (Form 2632) – Division for Children, Youth & Families, Child Development Bureau – Submitted by child care providers enrolled through DHHS to receive payments for providing child care through the Child Care and Development Fund Scholarships. 06/30/2009

Child Care Provider Verification (Form 2530) – Division for Children, Youth and Families, Child Development Bureau – Form 2530 is required to verify provider requirements and ensure the children being cared for are “linked” to the child care provider. 06/30/2009

Child Care Payment Request Invoice & Instructions (Form 2500) – Division for Children, Youth and Families, Child Development Bureau – Invoice (Form 2500) submitted by child care providers to receive payment for providing care to children whose parents qualify for the Child Care and Development Fund scholarship. 06/30/2009

Direct Deposit Authorization Agreement (Form 2637) – Child Development Bureau – This form is used by providers to enroll for Electronic Funds Transfer. 06/30/2009

License-Exempt Child Care Provider Agreement (Form 2631) – Division for Children Youth & Families, Child Development Bureau – For Child Care Providers to receive payments for providing child care through the Child Care and Development Fund Scholarships 06/30/2009

Provider Enrollment and Registration Packet (Form 2620) – Division for Children, Youth and Families, Child Development Bureau – Form 2620 and Alternate W-9 Form-CIS must be completed in order to enroll and register as a child care provider with DHHS. Allows provider to be eligible to receive payment for eligible children. 05/01/2001

Verification for a Child with a Disability – Division for Children, Youth and Families, Child Development Bureau – Form 2628, allows child care providers who care for children with a disability to receive a supplemental rate of reimbursement from DHHS.

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