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Recognizing that the COVID-19 pandemic is causing an unprecedented financial hardship for many Montgomery County residents, This special appropriation will make it possible for school-age child care providers to open licensed child care programs in public school buildings to support working parents.

Note: Maximum payment for a childcare center, $1,309.58 Maximum payment for a family provider, $1,001.43

*You can submit for 20 children per invoice form

Provider Information

General Information

Provider Type

Center

Family

Provider Name

Provider Phone Number

Provider Contact Phone Number

Provider contact Email

Provider Fiscal Information

Provider CVRS (County Vendor Registration System) ID

Monthly Provider Rate

Invoice Month

Child(ren) Information

To expedite processing - provide the Child ID from a School Age Grant Voucher - Child's CSSP ID

Child 1 - Full Name & Date of Birth (MM/DD/YY)

Child 1 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 1 - CSSP ID

Child 2 - Full Name & Date of Birth (MM/DD/YY)

Child 2 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 2 - CSSP ID

Child 3 - Full Name & Date of Birth (MM/DD/YY)

Child 3 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 3 - CSSP ID

Child 4 - Full Name & Date of Birth (MM/DD/YY)

Child 4 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 4 - CSSP ID

Child 5 - Full Name & Date of Birth (MM/DD/YY)

Child 5 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 5 - CSSP ID

Child 6 - Full Name & Date of Birth (MM/DD/YY)

Child 6 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 6 - CSSP ID

Child 7 - Full Name & Date of Birth (MM/DD/YY)

Child 7 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 7 - CSSP ID

Child 8 - Full Name & Date of Birth (MM/DD/YY)

Child 8 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 8 - CSSP ID

Child 9 - Full Name & Date of Birth (MM/DD/YY)

Child 9 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 9 - CSSP ID

Child 10 - Full Name & Date of Birth (MM/DD/YY)

Child 10 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 10 - CSSP ID

Child 11 - Full Name & Date of Birth (MM/DD/YY)

Child 11 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 11 - CSSP ID

Child 12 - Full Name & Date of Birth (MM/DD/YY)

Child 12 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 12 - CSSP ID

Child 13 - Full Name & Date of Birth (MM/DD/YY)

Child 13 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 13 - CSSP ID

Child 14 - Full Name & Date of Birth (MM/DD/YY)

Child 14 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 14 - CSSP ID

Child 15 - Full Name & Date of Birth (MM/DD/YY)

Child 15 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 15 - CSSP ID

Child 16 - Full Name & Date of Birth (MM/DD/YY)

Child 16 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 16 - CSSP ID

Child 17 - Full Name & Date of Birth (MM/DD/YY)

Child 17 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 17 - CSSP ID

Child 18 - Full Name & Date of Birth (MM/DD/YY)

Child 18 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 18 - CSSP ID

Child 19 - Full Name & Date of Birth (MM/DD/YY)

Child 19 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 19 - CSSP ID

Child 20 - Full Name & Date of Birth (MM/DD/YY)

Child 20 - Number of Days Absent & Reimbursement from State Scholarship Program (CCSP)/WPA/Equity Hub

Child 20 - CSSP ID

Provider Consent, Confirmation, and Signature

Invoice Number

You will be provided with a Invoice Number upon submission.

I verify that the information I have provided on this invoice, and all information submitted in support of this invoice is true, correct and complete. I understand that my invoice request can be denied payment if the provider is making false or incorrect statements or failing to report changes.I understand that I have the right to appeal if I am not satisfied with the action taken on my invoice by the COVID-19 Shool-Age Subsidy Program (CSSP).

My request must be filed within ten (10) working days from the date of the notice of decision.I hereby give DHHS permission to contact me by telephone, text or email.

I swear (or affirm) that all information on this invoice is true, correct and complete to the best of my ability, knowledge and belief.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

NOTE: After you click on Submit - keep the receipt numbers for your records. You will be given the option of downloading a PDF version of your invoice - please download as you cannot access this application after submittal.