Authorization Agreement for Direct Deposit Signature Sample Clauses

Authorization Agreement for Direct Deposit Signature. Sign and date the form. The signature must be that of the provider. CCAP 15R Rev. 10/11 12/10 Issue Obsolete Louisiana Department of Children and Family Services Child Care Assistance Program OFFICE USE ONLY New Provider Rate Change CHOW CHOL Provider Rate Agreement New license/other Name of Provider Tips Provider No. License No. If Applicable Physical Street Address City, State Zip Code Mailing Address, If Different From Above City, State Zip Code Phone Number Cell Phone Number Class A Military Provider FCDCH Provider Provider in Child’s Home School Program Provider Rate changes should be promptly reported to Provider Directory at the address below. Please complete the following and include verification of your rates (notice to parents, such as newsletter, bulletin, memo, etc.) A CCAP Rate and Availability Form will be sent for each child in your case and must be completed and returned in order for you to be paid. Do you have a Class A license? Yes No Are you a Head Start Program? Yes No Do you have special rates for more than one child in a family? Yes No No Rate: Do you serve children with disabilities ages 13 - 17? Yes Do you serve children under age 18 who have special care needs because of a mental, physical, or emotional disability, requires specialized facilities, lower staff ratio, or specially trained staff to meet his/her developmental and physical needs? Yes No If yes, is the rate for this child higher, lower, or the same for other children for whom you provide care? Higher Lower Same Do you participate in the Child and Adult Care Food Program? Yes No Rates Charged Per Child