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Get Child Care Payment

Ur payment has been delayed more than one month (ex. Do not send this form in October unless you are missing a payment for August or earlier.) DATE: ./ RETURN TO: Child Care Support Services 109 East 16th Street, 3rd Floor New York, NY 10003 Fax #: (212) 835-8253 or (212) 835-8252 / PARENT'S NAME CHILD/REN NAMES START DATE OF CARE 1 PA CASE NUMBER: 2 ACCIS CASE NUMBER: 3 DAY TIME TELEPHONE NUMBER: 4 Attach page(s) for additional children. PROVIDER/PROGRAM INFORMATION: PROVIDER/ PRO.

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