SFN 616, Child Care Request for Payment 400-28-165-45

(Revised 10/1/16 ML #3327)

View Archives

 

 

SFN 616, Child Care Request for Payment is completed by the child care provider identifying the monthly charges and hours for the child(ren) while in their care. Once completed, the provider and caretaker must sign and date the form prior to submission.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms.

 

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.