Statement for Providers with Assistants

If you are a licensed provider who uses an assistant or helper, this completed form must be on file at the WECA food program office so that your claims process properly.

This form does not expire until you inform WECA that you no longer use an assistant or helper in your child care business.

I HEREBY CERTIFY to the best of my knowledge that this information is true, correct, and in accordance with the terms of our existing agreement and that records are available to support this information. I understand that this information is being given in connection with the receipt of federal funds and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes.

I understand that it is my responsibility to inform WECA whether or not I currently use an assistant or helper in my child care business.

Check statement that applies to you

4 + 4 =

This site is registered on as a development site.