Section 1 of 7 in this document
Provider Invoice Form

The voucher end-date is subject to available funding and the parent continuing to meet WPA eligibility requirements. Parent and provider will be notified of changes affecting enrollment and modifying the period of authorization.

You will receive payment within fifteen (15) business days of the date the invoice is received.

For large Center providers with multiple locations - we advise that you submit vouchers per location to ensure correct payment.

For easy completion - you should have the WPA voucher on hand - as information from the program voucher is required to complete the invoice.

*You can submit for only 20 children per invoice form

Provider Information

General Information

Provider Type

Provider Address

Provider Contact Name

Provider Fiscal Information

Section 2 of 7 in this document

Child(ren) Information

Child 1 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 1 start care during the month of this invoice?

Child-1: Enrollment Date

Did Child 1 exit care during the month of this invoice?

Child-1: Exit Date

Child 2 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 2 start care during the month of this invoice?

Child-2: Enrollment Date

Did Child 2 exit care during the month of this invoice?

Child-2: Exit Date

Child 3 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 3 start care during the month of this invoice?

Child-3: Enrollment Date

Did Child 3 exit care during the month of this invoice?

Child-3: Exit Date

Child 4 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 4 start care during the month of this invoice?

Child-4: Enrollment Date

Did Child 4 exit care during the month of this invoice?

Child-4: Exit Date

Child 5 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 5 start care during the month of this invoice?

Child-5: Enrollment Date

Did Child 5 exit care during the month of this invoice?

Child-5: Exit Date

Section 3 of 7 in this document

Child 6 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 6 start care during the month of this invoice?

Child-6: Enrollment Date

Did Child 6 exit care during the month of this invoice?

Child-6: Exit Date

Child 7 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 7 start care during the month of this invoice?

Child-7: Enrollment Date

Did Child 7 exit care during the month of this invoice?

Child-7: Exit Date

Child 8 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 8 start care during the month of this invoice?

Child-8: Enrollment Date

Did Child 8 exit care during the month of this invoice?

Child-8: Exit Date

Child 9 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 9 start care during the month of this invoice?

Child-9: Enrollment Date

Did Child 9 exit care during the month of this invoice?

Child-9: Exit Date

Child 10 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 10 start care during the month of this invoice?

Child-10: Enrollment Date

Did Child 10 exit care during the month of this invoice?

Child-10: Exit Date

Section 4 of 7 in this document

Child 11 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 11 start care during the month of this invoice?

Child-11: Enrollment Date

Did Child 11 exit care during the month of this invoice?

Child-11: Exit Date

Child 12 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 12 start care during the month of this invoice?

Child-12: Enrollment Date

Did Child 12 exit care during the month of this invoice?

Child-12: Exit Date

Child 13 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 13 start care during the month of this invoice?

Child-13: Enrollment Date

Did Child 13 exit care during the month of this invoice?

Child-13: Exit Date

Child 14 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 14 start care during the month of this invoice?

Child-14: Enrollment Date

Did Child 14 exit care during the month of this invoice?

Child-14: Exit Date

Child 15 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 15 start care during the month of this invoice?

Child-15: Enrollment Date

Did Child 15 exit care during the month of this invoice?

Child-15: Exit Date

Section 5 of 7 in this document

Child 16 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 16 start care during the month of this invoice?

Child-16: Enrollment Date

Did Child 16 exit care during the month of this invoice?

Child-16: Exit Date

Child 17 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 17 start care during the month of this invoice?

Child-17: Enrollment Date

Did Child 17 exit care during the month of this invoice?

Child-17: Exit Date

Child 18 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 18 start care during the month of this invoice?

Child-18: Enrollment Date

Did Child 18 exit care during the month of this invoice?

Child-18: Exit Date

Child 19 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 19 start care during the month of this invoice?

Child-19: Enrollment Date

Did Child 19 exit care during the month of this invoice?

Child-19: Exit Date

Child 20 - Information - (Refer to your WPA Voucher for - the Child WPA ID, WPA Voucher ID, Monthly WPA Subsidy Rate, and Provider Site information)

Did Child 20 start care during the month of this invoice?

Child-20: Enrollment Date

Did Child 20 exit care during the month of this invoice?

Child-20: Exit Date

Section 6 of 7 in this document

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

I understand that I should receive payment within fifteen (15) business days of the date the invoice is received by the Working Parents Assistance (WPA) Program. I hereby give DHHS permission to contact me by telephone, text, or email.

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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.