Children Daily Attendance Sheet

Child's Name
Time In Parent Signature** Time Out Parent Signature**
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Director/Owner Signature Date
DHS 9800 A2D (7/1/2007) **Parent signature is required as disclosed in the 9800 agreement for payment of vouchers.
DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILDCARE & EARLY CHILDHOOD EDUCATION
DAILY CHILD ATTENDANCE FORM
Parent/Guardian/Authorized Representative Certification of Attendance: By my signature below, I declare
under penalty of perjury that the information is true and that my child/children were provided services at the above
location and on the days and times listed below. I understand that I must repay any overpayment resulting from false or
incorrect information and that I may be prosecuted for fraud.
Provider Certificaiton: I declare under penalty of perjury that the above information is true and that these children were provided services at the above location and
on the days and times listed above. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for
fraud.
Facility Name_____________________ Facility Number ___________ Date of Service ____________
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