[LE-21] Safety & Quality Enhancement Reimbursement Form - ENGLISH

  • [LE-21] Safety & Quality Enhancement Reimbursement Form

    For License Exempt Family Child Care Providers Participating in ERDC Subsidy

  • Who is eligible? License exempt Family Child Care Providers participating in ERDC Subsidy.
    What is reimbursable? The reimbursement will be available for the cost of equipment, or facility repairs that were directly paid by the program and have not been paid by a third party to help comply with DELC health and safety requirements. The reimbursement shall not exceed two hundred fifty dollars ($250.00) per year.
    Requirements for payments:

    1. Original receipt/s showing payment.
    2. WOU Substitute W-9 with information verifiable with IRS.

     

    Questions: 503-838-8008, tripayments@wou.edu

  • Format: (000) 000-0000.
  • Do you provide childcare to infants or toddlers (ages 0-3)?*
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    • End items 
    • How did you learn about this reimbursement?*

    • Include the following with this form: (Note: Forms with missing information will be held for payment until it is received.)

      1. Original receipt/s
      2. WOU Substitute W-9
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    • Payment Information:

      (Must match WOU Substitute W-9).

    • By signing I hereby affirm that the above information is true and accurate and that the costs were paid directly by myself/program and have not been paid by a third party.

    • Date*
       - -

  • Demographics Questionnaire

    You may choose not to provide demographic information. It will not affect the status of your reimbursement/stipend.
    • Race/Ethnicity 
    • 1. Which of the following describes your racial or ethnic identity? Please check All that apply.
    • NATIVE AMERICAN 
    • NATIVE AMERICAN
    • HISPANIC or LATINX 
    • HISPANIC or LATINX
    • ASIAN 
    • ASIAN
    • NATIVE HAWAIIAN or PACIFIC ISLANDER 
    • NATIVE HAWAIIAN or PACIFIC ISLANDER
    • BLACK 
    • BLACK
    • MIDDLE EASTERN 
    • MIDDLE EASTERN
    • WHITE 
    • WHITE
    •  
  • Should be Empty: