FBS Billing Monthly billing form for child care providers to fill out for payment through FBS REMEMBER: Submit this form by 5th of the month following service. Billings submitted after the 5th will be processed the following month. Billings 60 days or later from the month of service will not be paid. Family TOTAL care costs must exceed the total child care assistance. Neither the employer nor United Way is responsible for any unpaid parent portion of child care expenses. 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 InformationEmployerSelect OnePFC, USAGreeley TribuneParent Name Child Name Assistance Amount EmployerSelect OnePFC, USAGreeley TribuneParent Name Child's Name Assistance Amount EmployerSelect OnePFC, USAGreeley TribuneParent Name Child Name Assistance Amount EmployerSelect OnePFC, USAGreeley TribuneParent Name Child Name Assistance Amount EmployerSelect OnePFC, USAGreeley TribuneParent Name Child Name Assistance Amount EmployerSelect OnePFC, USAGreeley TribuneParent Name Child Name Assistance Amount EmployerSelect OnePFC, USAGreeley TribuneParent Name Child Name Assistance Amount EmployerSelect OnePFC, USAGreeley TribuneParent Name Child Name Assistance Amount Upload sign in/out sheet documenting attendanceAccepted 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) MM slash DD slash YYYY Δ
