Form AD 838, Statement of Monies Paid for 24-Hour Care of Children Instructions

Please provide the amount in dollars to be recorded by the county.

Enter the county check number for the eighth payment record.

Enter the classification code for the eighth payment record, referring to the *Classification section for valid codes.

Enter the type of case code for the eighth payment record, referring to the **Type of Case section for valid codes.

Enter the full name and address of the caretaker for the eighth payment record.

Enter the full name and date of birth of the child for the eighth payment record.

Enter the court case number for the eighth payment record.

Enter the date of the original court decree for the eighth payment record.

Enter the month or the number of days for which the eighth payment record is made.

Enter the amount paid by the county for basic maintenance for the eighth payment record.

Enter the amount paid by the county for social services for the eighth payment record.

Enter the amount claimed by the county for basic maintenance for the eighth payment record.

Enter the amount claimed by the county for social services for the eighth payment record.

Enter the county check number for the eleventh payment record.

Enter the classification code for the eleventh payment record. Refer to the *Classification section below for options.

Enter the type of case code for the eleventh payment record. Refer to the **Type of Case section below for options.

Enter the full name and address of the caretaker for the eleventh payment record.

Enter the full name and birthday of the child for the eleventh payment record.

Enter the court case number associated with the eleventh payment record.

Enter the date of the original court decree for the eleventh payment record.

Enter the month or the number of days for which this eleventh payment record is made.

Enter the amount of basic maintenance payment made by the county for the eleventh payment record.

Enter the amount paid by the county for social services for the eleventh payment record.

Enter the amount of basic maintenance payment claimed by the county for the eleventh payment record.

Enter the amount claimed by the county for social services for the eleventh payment record.

Enter the check number assigned by the county for this payment record.

Enter the classification code for the placement type.

Enter the type of case code for this payment record.

Enter the full name and address of the caretaker associated with this payment record.

Enter the full name and birthday of the child for this payment record.

Enter the court case number related to this payment record.

Enter the date of the original court decree.

Enter the month or the number of days for which the payment is made.

Enter the amount paid by the county for basic maintenance for this record.

Enter the amount paid by the county for social services for this record.

Enter the amount claimed by the county for basic maintenance for this record.

Enter the amount claimed by the county for social services for this record.

Enter the county check number associated with this payment record.

Enter the classification code for the type of placement.

Enter the type of case code for the payment record.

Enter the full name and address of the caretaker receiving the payment.

Enter the full name and birthday of the child for whom the payment is made.

Enter the court case number associated with the child.

Enter the date of the original court decree.

Enter the month or the number of days for which the payment is made.

Enter the amount of basic maintenance payment paid by the county.

Enter the amount for social services paid by the county.

Enter the amount of basic maintenance payment claimed by the county.

Enter the amount for social services claimed by the county.

Please provide the county check number for this payment record.

Please enter the classification code for the care provided.

Please enter the type of case code for this record.

Please provide the full name and address of the caretaker.

Please enter the child's full name and date of birth.

Please provide the court case number associated with this record.

Please enter the date of the original court decree.

Please enter the month or the number of days for which this payment is made.

Please enter the amount paid by the county for basic maintenance.

Please enter the amount paid by the county for social services.

Please enter the amount claimed by the county for basic maintenance.

Please enter the amount claimed by the county for social services.

Enter the county check number for the ninth payment record.

Enter the classification code for the ninth payment record, referring to the codes provided at the bottom of the form.

Enter the type of case code for the ninth payment record, referring to the codes provided at the bottom of the form.

Enter the full name and address of the caretaker for the ninth payment record.

Enter the full name and birthday of the child for the ninth payment record.

Enter the court case number for the ninth payment record.

Enter the date of the original court decree for the ninth payment record.

Enter the month or the number of days for which the payment is made for the ninth payment record.

Enter the basic maintenance payment amount paid by the county for the ninth payment record.

Enter the social services amount paid by the county for the ninth payment record.

Enter the basic maintenance payment amount claimed by the county for the ninth payment record.

Enter the social services amount claimed by the county for the ninth payment record.

Enter the county check number for the payment.

Enter the classification code or description for the payment.

Enter the type of case code for the payment.

Enter the full name and address of the caretaker.

Enter the full name and birthday of the child.

Enter the court case number associated with the child.

Enter the original date of the court decree.

Enter the month or the number of days for which the payment is made.

Enter the amount paid by the county for basic maintenance.

Enter the amount paid by the county for social services.

Enter the amount claimed by the county for basic maintenance.

Enter the amount claimed by the county for social services.

Enter the county check number for the seventh payment record.

Enter the classification code for the type of care placement for the seventh payment record.

Enter the type of case code for the seventh payment record.

Enter the full name and address of the caretaker for the seventh payment record.

Enter the full name and birthday of the child for the seventh payment record.

Enter the court case number associated with the seventh payment record.

Enter the date of the original court decree for the seventh payment record.

Enter the month or the number of days for which this payment is made for the seventh payment record.

Enter the amount paid by the county for basic maintenance for the seventh payment record.

Enter the amount paid by the county for social services for the seventh payment record.

Enter the amount claimed by the county for basic maintenance for the seventh payment record.

Enter the amount claimed by the county for social services for the seventh payment record.

Provide the county check number for this payment record.

Enter the classification code for the care provided.

Enter the type of case code.

Provide the full name and address of the caretaker.

Enter the full name and birthday of the child.

Provide the court case number associated with this record.

Enter the date of the original court decree.

Specify the month or the total number of days for which this payment is made.

Enter the amount of basic maintenance payment paid by the county.

Enter the amount for social services paid by the county.

Enter the amount of basic maintenance payment claimed by the county.

Enter the amount for social services claimed by the county.

Enter the name of the Treasurer responsible for paying the stated monies.

Enter the month during which the statement of monies was paid.

Enter the last two digits of the year for which the statement of monies was issued.

Provide the county check number for this payment record.

Enter the classification code for the type of care provided, as defined in the legend.

Enter the type of case code, as defined in the legend, for this payment record.

Provide the full name and address of the caretaker receiving this payment.

Provide the full name and birthday of the child for whom this payment is made.

Enter the court case number associated with this record.

Provide the date of the original court decree.

Enter the month or the number of days for which this payment is being made.

Enter the basic maintenance payment amount paid by the county for this record.

Enter the social services payment amount paid by the county for this record.

Enter the basic maintenance payment amount claimed by the county for this record.

Enter the social services payment amount claimed by the county for this record.

Enter the county check number associated with this payment record.

Enter the classification code for the placement type.

Enter the code indicating the type of care case.

Enter the full name and address of the caretaker.

Enter the full name and birthday of the child.

Enter the court case number for the child.

Enter the date of the original court decree.

Enter the month or the number of days for which this payment is made.

Enter the amount paid by the county for basic maintenance.

Enter the amount paid by the county for social services.

Enter the amount claimed by the county for basic maintenance.

Enter the amount claimed by the county for social services.

Please enter the total amount paid by the county for basic maintenance payments. Fill only if 'Basic Maintenance Payment Claimed by County', 'Claimed Basic Maintenance Payment', 'Amount Claimed - Basic Maintenance', 'County Claimed Basic Maintenance', 'Amount Claimed - Basic Maintenance', 'County Claimed Basic Maintenance', 'Seventh Payment Record County Claimed Basic Maintenance', 'Eighth Payment Claimed Basic Maintenance Payment', 'Ninth Payment Record Claimed Basic Maintenance Payment', 'Claimed Basic Maintenance Payment', 'Eleventh Record Amount Claimed by County - Basic Maintenance' are filled, any.

Please enter the total amount paid by the county for social services. Fill only if 'Social Services Payment Claimed by County', 'Claimed Social Services Payment', 'Amount Claimed - Social Services', 'County Claimed Social Services', 'Amount Claimed - Social Services', 'County Claimed Social Services', 'Seventh Payment Record County Claimed Social Services', 'Eighth Payment Claimed Social Services Payment', 'Ninth Payment Record Claimed Social Services Amount', 'Claimed Social Services Payment', 'Eleventh Record Amount Claimed by County - Social Services' are filled, any.