ICCP Form

Monthly Dependent Care Charges:

Child Care Provider Form
Use this form to report charges for Child Care
1. Parents: Complete part A Providers: Complete parts B-D

2. Sign and send the completed form to the Department
Contact the Department
Mail: P.O. Box 83720, Boise, ID 83720-0026

Phone: 1-877-456-1233

Fax: 1-866-434-8278

Email: MyBenefits@dhw.idaho.gov
Part A: Parent information
Name*

First nameMiddle nameLast name
Case number or Social Security number*
Parent Address*

Parent address

Street Address Line 2

CityState

Zip code
Phone Number*
Phone type (choose one)*

HomeWorkCell
Email Address*
Part C: Tell us about the child receiving care
First Name Last Name*
Date of Birth*

MonthDayYear
Date
Is the owner or any employee related to this child?*

NoYes
If yes, check all that apply

Is the owner of the facility the parent or legal guardian?Is the child's direct care being provided by a parent or legal guardian?
Signature
Charges must be agreed upon by both parties. Final charges may be submitted with only the provider's signature.
Parent Name*
Parent signature*

Clear
Date

MonthDayYear
Date
Should be Empty: