FBS Billing corrections - United Way of Weld County

FBS Billing – CORRECTION

ORIGINAL SUBMISSION ID#(Required)

ORIGINAL SUBMISSION DATE(Required)

ORIGINAL SERVICE PROVIDED DATE(Required)

PLEASE ONLY USE THIS FORM IF YOU NEED TO SUBMIT A CHANGE FOR AN INVOICE ALREADY SUBMITTED.

Child Care Provider(Required)

First Last

Business Name (if applicable)

Email(Required)

Service Provided(Required)

Month Year

Address(Required)

Street Address City State Zip

Phone(Required)

Billing Information

Employer

Parent Name

Child Name

Assistance Amount

Employer

Parent Name

Child's Name

Assistance Amount

Employer

Parent Name

Child Name

Assistance Amount

Employer

Parent Name

Child Name

Assistance Amount

Employer

Parent Name

Child Name

Assistance Amount

Employer

Parent Name

Child Name

Assistance Amount

Employer

Parent Name

Child Name

Assistance Amount

Employer

Parent Name

Child Name

Assistance Amount

Upload sign in/out sheet documenting attendance

Accepted file types: jpg, jpeg, png, gif, doc, docx, xls, xlsx, pdf, Max. file size: 300 MB.

I declare that the above information is accurate, reflects actual services provided, and meets the United Way of Weld County Child Care Financial Support Program requirements. Parent payment and UWWC payment cannot exceed the TOTAL cost of care.

Signed(Required)

Date(Required)