Form AD 838, Statement of Monies Paid for 24-Hour Care of Children Completed Form Examples and Samples
View practical examples and samples of the Form AD 838, Statement of Monies Paid for 24-Hour Care of Children. Learn how to accurately fill out this form with our step-by-step guides and annotated templates.
Example: Filling Form AD 838 for 24-Hour Child Care Reimbursements
How this form was filled:
This example demonstrates how our AI processes unstructured administrative notes to accurately populate the 'Statement of Monies Paid for 24-Hour Care of Children' (Form AD 838). By parsing natural language logs from a county treasurer's monthly review, the AI extracts specific payment codes, court decree dates, and maintenance amounts, mapping them to the corresponding rows in the official document automatically.
Source document used: Treasurer's Administrative Monthly Reconciliation Log
Memorandum from the Treasurer’s Office, October 2026: Regarding the monthly reconciliation for 24-hour child care services, our office processed payments for the current billing cycle. During October 26, check number 99014 was issued for Sarah Miller, residing at 123 Maple St, Springfield, for the care of child Leo Miller (DOB: 05/12/2018). This case (CR-2024-88) originated on 01/15/2024; the maintenance payment of $450 and social services fee of $120 were fully processed. Similarly, for the second entry, check 99015 was issued to David Thompson of 456 Oak Ave for Jane Doe (DOB: 11/20/2019), court case CR-2024-89, decree dated 02/10/2024, reflecting $500 in maintenance and $150 in social services. We have cross-referenced these against the state guidelines. Please note that all claimed amounts match the paid amounts exactly for this period. We are still waiting on audit reports for the third through eleventh records; for now, these initial two records are finalized. Treasurer Jane Doe has signed off on these entries to ensure compliance with the 24-hour care oversight mandates. All payments are restricted to authorized foster placements. Please ensure the 'Statement Year' is recorded as '26' on the summary cover sheet. Any discrepancies found in future audits must be routed directly to the Department of Children and Family Services before year-end processing closes.
Information used to fill out the document:
- Statement Details: Treasurer Jane Doe, October 2026
- Payment Record 1: Check 99014, Sarah Miller, Leo Miller (05/12/2018), Case CR-2024-88
- Payment Amounts: Basic Maintenance $450, Social Services $120
- Payment Record 2: Check 99015, David Thompson, Jane Doe (11/20/2019), Case CR-2024-89
- Claimed Amounts: Basic Maintenance $500, Social Services $150
What this filled form sample shows:
- Contextual entity recognition for person and child names
- Smart date normalization from natural language formats
- Automated mapping of disparate data points into specific form line items
- Handling of summary-level fields based on individual row input
- Verification of payment categories versus service types
Form specifications and details:
| Form Name: | Form AD 838, Statement of Monies Paid for 24-Hour Care of Children |
| Document Scope: | County-level reimbursement accounting |
| Target Audience: | Social services case workers and county treasurers |
| Key Compliance Focus: | Tracking court decree dates and maintenance vs. social service splits |
| Categories: | CAR forms, child care forms, NJ state forms, PA state forms, state ID forms, L.A. Care forms |
| Created: | May 25, 2026 11:19 PM |