Time Sheet

Date of Service
Day of Week

Start Time

End Time

Total number of Hours

Childcare Provider Charges

Number of Children

Rate per Hour

Hourly Rate$___ X Total Hours=

Mileage $.25 X ___ Miles =

Provider Total = Hourly + Mileage (To be Paid in Cash)

Agency Referral Charge = Daily/Weekly/Monthly/Hotel: $8/hr X Total hrs Annual Members: $4/hr X Total hrs

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.