Child Care Co-Payment Agreement Form

Main Office: 222 East Central Parkway • Cincinnati, Ohio 45202-1225
General Information: (513) 946-1000
General Information TDD: (513) 946-1295
www.hcjfs.org
Child Care Co-Payment Agreement Form
Ohio Administrative Code 5101:2-16-39 (H) requires Child Care providers to establish a
written agreement for payment of the co-payment and fees, signed by the provider and
caretaker. Providers must retain the original form in their records and submit a copy to
HCJFS only when advising HCJFS of the consumer’s non-payment of fees.
Caretaker:
Provider:
Address:
Address:
Telephone:
Telephone:
I, ___________________________, agree to pay the assigned weekly co-payment (fee
determined by HCJFS) to the provider. The due date for payment is:
Failure to pay the co-payment by the agreed upon date, will result in notifying the HCJFS of
the delinquent co-payment and possible termination of services.
The signatures below signify agreement with the statements above.
Signature of Caretaker:
Date:
Signature of Provider:
Date:
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If the consumer’s co-payment fee is delinquent more than ten calendar days from the due
date established in this written co-payment agreement, submit a copy of this document and
the HCJFS 4671 – Delinquent Fee Form by fax or mail to:
Hamilton County Job & Family Services
Child Care Department
222 E. Central Parkway
Cincinnati OH 45202
Fax: 513-946-1830
HCJFS 0139 (REV. 10-14)