Common use of Provider Certification Clause in Contracts

Provider Certification. I declare under penalty of perjury that the above information is true and that these children were provided services at the above location and on the days and times listed above. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for fraud. Director/Owner Signature Date DHS 9800 A2D (7/1/2007) **Parent signature is required as disclosed in the 9800 agreement for payment of vouchers. Daily Attendance Form Example DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILDCARE & EARLY CHILDHOOD EDUCATION WEEKLY CHILD ATTENDANCE FORM Facility Name Facility Number Week of Parent/Guardian/Authorized Representative Certification of Attendance: By my signature below, I declare under penalty of perjury that the information is true and that my child was provided services at the above location and on the days and times listed below. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for fraud. Child's Name TIME Sunday Monday Tuesday Wednesday Thursday Friday Saturday Parent Signature** Date 1 INOUT 2 INOUT 3 INOUT 4 INOUT 5 INOUT 6 INOUT 7 INOUT 8 INOUT 9 INOUT 10 INOUT 11 INOUT Provider Certification: I declare under penalty of perjury that the above information is true and that these children were provided services at the above location and on the days and times listed above. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for fraud. **Parent signature is required as disclosed in the 9800 agreement for payment of vouchers. DHS 9800 A2W (7/1/2007) Director/Owner Signature Date ARKANSAS DEPARTMENT OF HUMAN SERVICES CHILD CARE AND DEVELOPMENT FUND (CCDF) PROGRAM PARTICIPANT AGREEMENT

Provider Certification. I declare under penalty of perjury that the above information is true and that these children were provided services at the above location and on the days and times listed above. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for fraud. Director/Owner Signature Date DHS 9800 A2D (7/1/2007) **Parent signature is required as disclosed in the 9800 agreement for payment of vouchers. ARKANSAS DEPARTMENT OF HUMAN SERVICES CHILD CARE AND DEVELOPMENT FUND (CCDF) PROGRAM PARTICIPANT AGREEMENT Daily Child Attendance Form Example DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILDCARE & EARLY CHILDHOOD EDUCATION WEEKLY CHILD ATTENDANCE FORM Facility Name Facility Number Week of Parent/Guardian/Authorized Representative Certification of Attendance: By my signature below, I declare under penalty of perjury that the information is true and that my child was provided services at the above location and on the days and times listed below. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for fraud. Child's Name TIME Sunday Monday Tuesday Wednesday Thursday Friday Saturday Parent Signature** Date 1 INOUT IN OUT 2 INOUT IN OUT 3 INOUT IN OUT 4 INOUT IN OUT 5 INOUT IN OUT 6 INOUT IN OUT 7 INOUT IN OUT 8 INOUT IN OUT 9 INOUT IN OUT 10 INOUT IN OUT 11 INOUT IN OUT Provider Certification: I declare under penalty of perjury that the above information is true and that these children were provided services at the above location and on the days and times listed above. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for fraud. **Parent signature is required as disclosed in the 9800 agreement for payment of vouchers. DHS 9800 A2W (7/1/2007) Director/Owner Signature Date ARKANSAS DEPARTMENT OF HUMAN SERVICES CHILD CARE AND DEVELOPMENT FUND (CCDF) PROGRAM PARTICIPANT AGREEMENT