Dependent Care Voucher Program: Monthly Cost Verification

Instructions to employee: This form may be printed out and given to the care provider for completion. When complete, please attach copy of payment receipt(s) and mail or hand carry to WORKlife Programs at the address shown below.

TO BE COMPLETED BY CARE PROVIDER

Name of care provider / agency:

Street address: Apt ##:

City: State: Zip code:

Provider business phone ##: - -

License ## or Federal ID ## of care provider or agency:

Name of licensing organization:

Johns Hopkins employee name:

Please list each individual in this family for whom you are providing care and their birth date:

Note to Care Provider: We can only reimburse care for one (1) dependent per family. If you are caring for more than one dependent for this employee, please place a check mark next to the dependent who is covered by this monthly verification.

Total amount paid by employee for one (1) dependent checked above: $

This bill covers (mm/dd/yyyy) / / to / /
(Example: This bill covers 01/06/2009 to 01/31/2009.)

Note to care provider: By signing below, you are verifying that the employee has paid you the above amount for the dates shown and that we may call you to confirm any information you have provided.

Care provider signature: ____________________________________ Date:________________
(Must be license holder's signature.)

Original, signed, verification form must be hand delivered or mailed to:

It is the employee's responsibility to submit this form accompanied by a copy of payment receipt(s) to WORKlife Programs for reimbursement. Reimbursement will be made monthly.

For assistance in completing the forms, please call  443-997-7000.