Sample Template for Use by Childcare Providers


Ask the childcare provider’s office to use this template on the provider’s letterhead and replace the bracketed information.


<Insert Today's Date>

<Insert Parent/Guardian’s Name and Address>

Re: <Insert Child's Name>

To Whom It May Concern:

Our records show we provided service(s) to <Child's Name> at <Name of Care Provider> on the following date(s) <Insert the Date(s) You Provided Service(s) for the Tax Year On the Notice>.

Our records reflect that the child lived at <Street Address, City, State, Zip Code (if the child moved during the year show all addresses)> during this time. Our records also reflect that the child’s parent or guardian during this time was <Insert Parent's or Guardian’s Name(s)>. The child’s parent's or guardian's address of record during this time was listed as <Insert Parent's or Guardian’s Address(es)>.


<Insert Signature of School/Day Care Official>
<Insert Title of School/Day Care Official>
<Insert Phone Number of School/Day Care Official>