JFS 01443, Request for Payment for Special Services for Children in Out-of-Home Care Instructions
This form contains 23 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Administrative Details | ||
| Region | Text |
Please enter the region associated with this request.
|
| Voucher Number | Text |
Please enter the voucher number for this payment request.
|
| Worker | Text |
Please enter the name of the worker associated with this request.
|
| Amount of Request | ||
| Amount of Request | Number |
Please provide the total amount being requested.
|
| Approving Administrator/Designee Name | ||
| Printed Name | Text |
Enter the printed name of the approving regional administrator or designee.
|
| Child Information | ||
| Child Name | Text |
Please enter the full name of the child.
|
| Child ID Number | Text |
Please enter the identification number for the child.
|
| General | ||
| Text8 | Text | |
| Text9 | Text | |
| Text10 | Text | |
| Text11 | Text | |
| Text12 | Text | |
| Text13 | Text | |
| Text15 | Text | |
| Text16 | Text | |
| Text17 | Text | |
| Text18 | Text | |
| Text19 | Text | |
| Text20 | Text | |
| Provider Information | ||
| Provider Name | Text |
Enter the full name of the provider.
|
| Provider Number | Text |
Enter the identification number assigned to the provider.
|
| Request and Reason for Request | ||
| Request and Reason for Request | Text |
Provide a detailed explanation of the request being made and the specific reasons justifying it.
|
| Resource Exploration Details | ||
| Resources Explored | Text |
Provide a detailed account of what other resources were explored for this request.
|