‘co208 11) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Child Care Administration PROVIDER/PARENT/GUARDIAN’S AGREEMENT FOR CHILD CARE CHARGES GRR GARE PROVIDERS ee a 2 ofS 8b- 061330} PRRENTIGUAROANS las COPE NER Fd - vecnitt_ Olivet Meidibod 2 Child Tocalyn Neighlooes 3" Child 5 mae FULL DAY sissy [PART DAV amram LINES 1-8 MUST BE COMPLETED tt_[iné [ed [te [tnd [30d T Provider's dally rate sms | |s 2. Meals Emer daly 008 (cost of meal is included inthe Provider's Daily aie on ine I, enter 0). = s 3, Transportation: Enter daily ost (eas of transportation is inched inthe Provider's Daily Rate on line 1, enter 0). = |= s 3 Addines 1 2&3 cote anown, TOTALS ARETHEPROVIDER'S | <2 s FULL DAY @ un ormew) | PART DAY (amrter ba) vagy apa at [20 : inter amount of Parent Guardian's daily DES Assigned Copaymant (See in Certificate of Authorization). ez s 7. Subtract line 6 from line 5 and enter amount. THIS IS THE DAILY RATE ze ns DES WILL REIMBURSE THE PROVIDER. Be" s ia SSG] FULL DAY im or moro) | PART DAY (ies hon 5) 8. Subtract line 7 from line 4 and enter amount. THIS IS THE DAILY | me AMOUNT OF THE PROVIDER RATE NOT SUBSIDIZED BY DES, | 75* [72 AND THE RESPONSIBILITY OF HE PARENT/GUARDIAN TO REIMBURSE THE PROVIDER. _ S. pees FREQUENCY OF PAYMENT] ~ AMOUNT OF PAYMENT Bs es: OL eid 200/00 cE cient rte ha ; seen Pa Ec peng, ee : "This Agreement for Child Care Charges will expire on (enter “ ‘End Date” jrom Certificate of Authorization)2617 — S612 (CC-208 (5-11) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Child Care Administration PROVIDER/PARENT/GUARDIAN’S AGREEMENT FOR CHILD CARE CHARGES. TRE DARE STR ( Sb* LOoOS tS PARERTICUARAN'S WOME Pe Ta) AB Utxandon Vac Woche ‘SALES HOES) et Las ye rotild Ayah Neigh Senna PART DAY (las han a) ist | 2nd [3rd AAiir Ss St Z S 2 Meals Enter dally cost (cost of meal is inched inthe Provider's Daly Rate on line I, enter 0) | s 3, Transportation: Enter daly cost (/ cost of transportation ix included in the : Provider's Daily Rate on line I, enter 0) : s ZF Addllines 1, 2, & 3, enter amount. TOTALS ARE THE PROVIDER'S PROJECTED DAILY CHILD CARE CHARGES. D ‘RATE/ASSIGNED COPA) mel F 5. Enter amount DES will subsidize the provider (See CC-2/4, Child Care Provider Rate Agreement) 5 Enter amount of Parent Guardian's daily DES Assigned Copaymant See Certificate of Authorization). 7. Subtract line 6 from line 5 and enier amount. THIS IS THE DAILY RATE | _ OD DES WILL REIMBURSE THE PROVIDER. seo AS e a, RESPONSIBLE "PULL DAY ive ormord_| PART DAY tas than ro) 3. Subtract line 7 from line 4 and enter amount. THIS IS THE DAILY T AMOUNT OF THE PROVIDER RATE NOT SUBSIDIZED BY DES, | Z ‘AND THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO Like REIMBURSE THE PROVIDER, . Registration Fees #) Ke. Age s Other Spec L-O s Other (Specify: s “Tis Agreement for Child Care Charges will expire on (enter “Authorization End Date” from Certificate of Authorizat see GNATURES (Provis w/Guan As the en ‘of the child(ren) in care, I agree to accept responsibilty for the payment of the DES Assigned Full/Part Day opsymenton ine 6, the Flat Day Changes Istedon line 8 or amy “Additonal Fes Copan ee - "Dé J! 2o17 BEE ee oe ‘Charges on line 7, the Full/Part Day Charges listed on line 8 or any “Additional Fees.” Santos souiee Tl JD Pole, fay DISTRIDUTTOR: Original fhe) tr Forde Copy (conan) for parenlguarion : ae boc o — Atlee On Nov