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AUTHORIZED UNITS OF CARE Full Name of Children Birth Date day/mo/yr Authorization Type A ATTN I Infant T Toddler C Child S School age E ENR Authorized Days of Care Hourly Care Part Time of hrs/day Full days per month TOTAL SUBSIDY AMT Enter Subsidy Amount for Each 6. Name of DPA Representative Representative s Phone Date Faxed CC2-06-3823 Rev 01/04 Form Distribution Fax DPA Director s office Page 1 of 2 ORIGINAL Child care provider COPY DPA field office FORM INSTRUCTIONS Manual authorizations...

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