Annex A - FEEE Form

Annex A: Parental Declaration Form for Free Early Education Entitlement (FEEE)
1. Setting details
Setting Name: Gledhow Primary School

Setting Ofsted URN: 107904
2. Child's details
First name*
Middle names
Surname*
Preferred Surname
Date of Birth*

DayMonthYear
Date
Ethnicity*
Gender*
3. Parent's details
Parent/Carer 1 Name*
Parent/Carer 1 NI Number*
Parent/Carer 1 DOB*

DayMonthYear
Date
Email*
example@example.com
Telephone*
Parent/Carer 2 Name*
Parent/Carer 2 NI Number*
Parent/Carer 2 DOB*

DayMonthYear
Date
Email*
example@example.com
Telephone*
4. Child's home information
Building name/no*
Street*
Area*
Town city*
Postcode*
5. 9 months to 23-month-olds (inclusive) of working families and all 2-year-old FEEE
To access the 9 months to 23-month-olds (inclusive) of working families and all 2-year-old FEEE your child must meet the eligibility criteria, as confirmed by your Eligibility or Early years Voucher code. Please enter below the Eligibility code or Early Years Voucher code for your child:
Eligibility Code 11 digit
Early Years Voucher Code
6. FEEE Additional 15 hours Entitlement
To access the 15 hours per funded week FEEE Additional Entitlement for your 3 or 4 year old, you must have applied for an Eligibility code via the HMRC's Eligibility code application and confirmed your eligibility with your childcare provider. Please indicate below if your child meets the criteria and input your voucher code.
Eligible for the FEEE Additional entitlement
Eligibility code 11 digit
7. Early Years Pupil Premium (EYPP)
The Early Years Pupil Premium (EYPP) is an additional sum of money paid to childcare providers for children of families in receipt of certain benefits and accessing 2-, 3- and 4-year- old FEEE. This funding will be used to enhance the quality of their early years experience by improving the teaching, learning and facilities and resources, to impact positively on your child's progress and development.

By signing this form, you consent to an eligibility check for EYPP. For more information, please speak to your childcare provider.
8. Disability Access Fund Declaration
Three- and four-year old children who are in receipt of child Disability Living Allowance (DLA) and are receiving the free entitlement are eligible for the Disability Access Fund (DAF DAF is paid to the child's early years setting as a fixed annual rate of £881 per eligible child. Please supply evidence of DLA to your provider.
Is your child in receipt of Disability Living Allowance DLA*
9. Attendance details
You need to agree and complete this Declaration Form with each setting your child attends for their FEEE entitlement (Eligible 9-month-olds to 2-year-olds), FEEE Universal entitlement (Eligible 3&4-year-olds) or FEEE Additional entitlement (Eligible 3/4-year-olds only) at least once per year (Financial Year April-March) in order to ensure that funding is paid fairly between them.

The entitlement per annum (Apr-Mar) is 570 hours for all ages plus, if eligible, 570 hours Additional Entitlement for 3- & 4-year-olds. Please speak to your childcare setting about the FEEE sessions they operate (hours and days) These should be detailed on your contract with them, and via child registers.

Your child can attend a maximum of two sites (refers to provider postcode) in a single day. It is the parent's decision how the funding is allocated between all providers who offer both FEEE Entitlement and Additional FEEE Entitlement. However, if one of the Providers only offers FEEE entitlement funded places, that Provider must inform the parent prior to the child taking up the place that they will claim FEEE Entitlement only.
My child is claiming FEEE with this setting from:
Claim start date*

DayMonthYear
Date
Until (this can be entered once known)
Claim end date

DayMonthYear
Date
My child is attending the following settings for the FEEE Entitlement for eligible 9- month-olds to 2-year-olds or the Universal FEEE Entitlement for 3&4-year-olds:
Setting Name A
Please enter either a. number of FEEE Additional hours attended OR b. total FEEE Additional hours attended in the term OR c. total FEEE Additional hours attended per year
Setting Name B
Please enter either a. number of FEEE Additional hours attended OR b. total FEEE Additional hours attended in the term OR c. total FEEE Additional hours attended per year
Setting Name C
Please enter either a. number of FEEE Additional hours attended OR b. total FEEE Additional hours attended in the term OR c. total FEEE Additional hours attended per year
Total Annual Additional FEEE hours Attended
My child is attending the following settings for the FEEE Additional Entitlement for eligible 3&4-year-olds:
Setting Name A
Please enter either a. number of FEEE Additional hours attended OR b. total FEEE Additional hours attended in the term OR c. total FEEE Additional hours attended per year
Setting Name B
Please enter either a. number of FEEE Additional hours attended OR b. total FEEE Additional hours attended in the term OR c. total FEEE Additional hours attended per year
Setting Name C
Please enter either a. number of FEEE Additional hours attended OR b. total FEEE Additional hours attended in the term OR c. total FEEE Additional hours attended per year
Total Annual Additional FEEE hours Attended
If your child attends any hours above the funded hours you are claiming, please indicate this here:
Hours Attended Above FEEE
If your child is splitting their free entitlement across two or more providers, please nominate the main setting where the local authority should pay the DAF/EYPP (this should be the provider claiming FEEE entitlement):
Setting Name
10. Parent/Carer/Guardian with legal responsibility declaration
Declaration: I (Name) Full name* Address Address*
confirm that the information I have provided above is accurate and true. I understand and agree to the conditions set out in this document and I authorise (Name of Provider/s)....Gledhow Primary School......

to claim free entitlement funding as agreed above on behalf of my child and inform me to which funding streams my child is eligible.

In addition, I also agree that the information I have provided can be shared with the local authority and Department for Education, who will access information from other government departments to confirm my child's eligibility for FEEE Entitlement or the FEEE Additional Entitlement and enable this provider to claim Early Years Pupil Premium (EYPP) or Disability Access Fund (DAF) on behalf of my child.
Parent/Carer/Guardian with legal responsibility*

Clear
Name*
Date*

DayMonthYear
Date
Childcare Provider

Clear
Name
Date

DayMonthYear
Date
If any of the above information changes a new parental declaration form mustbe completed immediately
Should be Empty:

Annex A: Parental Declaration Form for Free Early Education Entitlement (FEEE)

1. Setting details

2. Child's details

3. Parent's details

4. Child's home information

5. 9 months to 23-month-olds (inclusive) of working families and all 2-year-old FEEE

6. FEEE Additional 15 hours Entitlement

7. Early Years Pupil Premium (EYPP)

8. Disability Access Fund Declaration

9. Attendance details

10. Parent/Carer/Guardian with legal responsibility declaration