Form Jfs 01292 - Publicly Funded Child Care Request For Ohio Ecc Payment Adjustment Page 2

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Sunday Begin Date
Child ID Number
SECTION V. REVISED PAYMENT INFORMATION
infant
toddler
preschool
school age
summer school age
Age Category of Child
(check one)
$
Customary Rate
(from CP)
$
Appendix Rate
(appendix to Rule 5101:2-16-41)
Child Special Needs
$
(from EA)
$
Child Special Needs Waiver
(from EA)
$
Non-traditional Care
Accreditation or Star Rating
(from CP)
NAEYC
NAFCC
NECPA
COA
NAC
ACSI
SUTQ Star Rated
SUTQ 2 Star Rated
SUTQ 3 Star Rated
SUTQ 4 Star Rated
SUTQ 5 Star Rated
$
Copayment Amount
$
(from EA)
Original Payment
Revised Payment
Adjustment Amount
Amount for Week
Amount for Week
$
$
$
Check one
overpayment
underpayment
SECTION VI. IN HOME AIDE (only complete if in home aide)
Customary Rate
Weekly Cost of Care
Copayment Amount
Number of Children
$
$
$
Original Payment
Revised Payment
Adjustment Amount
Amount for Week
Amount for Week
$
$
$
check one
overpayment
underpayment
SECTION VII. COUNTY CONTACT
County
County Worker Phone Number
County Worker First Name
County Worker Last Name
SECTION VIII. FOR COUNTY USE ONLY
Check here if Adjustment is denied and list reason. Keep in County files.
JFS 01292 (Rev. 9/2014)
Page 2 of 2

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