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Las Vegas Urban League Child Care Subsidy Program 2470 N Decatur Blvd Suite 150 Las Vegas NV 89108 702-629-2561 Fax 702-629-6232 Service Month Service Year Bill Annual Fee Bill Registration Fee Child Care Enrollment Attendance Verification EAV Form PLEASE DO NOT USE WHITE OUT Provider Name Provider Tax ID or SSN Provider Address City Zip Parent Name Child Track DATE On Track Child DOB Overnight Child Name Is the client s co-payment current Provider s Initials TIME IN TIME OUT Yes Phone Child UPI or SSN Child School Hours No Parent Signature for Authorization of Discretionary Day If NO balance due Please attach a record of monies owed by client The timesheet must be completed DAILY by the client or other authorized individual. If a client chooses to use a discretionary day the client must sign in the space provided for that date. A separate timesheet must be completed for EACH child. Timesheets must be COMPLETED and SIGNED by both the CLIENT AND PROVIDER at the end of each month to receive payment. Timesheets are DUE in the office listed above by 5 00 PM on the FIFTH business day of the month following the service period. Timesheets received after the FIFTH business day will be processed at the next available reimbursement period. Billings and registration/annual fees must be submitted not later than ninety 90 days after the month of service or are not eligible for payment approval* We the undersigned certify the accuracy of the information submitted and understand that this information may be audited by either the Division of Welfare and Supportive Services DWSS or The Urban League Child Care Subsidy Program and that any overpaid benefits will be recovered* Provider Signature. A separate timesheet must be completed for EACH child. Timesheets must be COMPLETED and SIGNED by both the CLIENT AND PROVIDER at the end of each month to receive payment. Timesheets are DUE in the office listed above by 5 00 PM on the FIFTH business day of the month following the service period. Timesheets are DUE in the office listed above by 5 00 PM on the FIFTH business day of the month following the service period. Timesheets received after the FIFTH business day will be processed at the next available reimbursement period. Timesheets received after the FIFTH business day will be processed at the next available reimbursement period. Billings and registration/annual fees must be submitted not later than ninety 90 days after the month of service or are not eligible for payment approval* We the undersigned certify the accuracy of the information submitted and understand that this information may be audited by either the Division of Welfare and Supportive Services DWSS or The Urban League Child Care Subsidy Program and that any overpaid benefits will be recovered* Provider Signature. A separate timesheet must be completed for EACH child. Timesheets must be COMPLETED and SIGNED by both the CLIENT AND PROVIDER at the end of each month to receive payment. Timesheets are DUE in the office listed above by 5 00 PM on the FIFTH business day of the month following the service period. Timesheets received after the FIFTH business day will be processed at the next available reimbursement period.