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Rogram payments are to be made directly to the provider. If the provider chooses to have a client paid directly, the provider must complete this form. Provider Name Address City Provider License/Approved Relative/Self-Certified/Tribal Number State Zip Code Social Security Number/EIN Number List the parent's name and the children's names. Parent's Name Child's Name Child's Name Child's Name Child's Name Child's Name Child's Name Service Month and Year this Child Care Authorization Wi.
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