Request for Travel Time

Attn: ________________
Request for Travel Time
Name: _______________________________ Case Number: _____________
In order to assist us in assessing your child care needs, please indicate the following:
Your provider’s address:
______________________________________
street address
______________________________________
city
(if more than one, please indicate):
zip code
______________________________________
street address
______________________________________
city
Your final destination:
zip code
______________________________________
street address
______________________________________
city
zip code
Your method of transportation (circle):
Car
Bus
Train
Walk
other:
____________________
The amount of travel time you are requesting from provider to activity way: _______ minutes
The amount of travel time you are requesting from activity to provider way: _______ minutes
Please explain why you are requesting this amount of transportation:
________________________________________________________________
________________________________________________________________
________________________________________________________________
I declare under penalty of perjury under the laws of the United States of America
and the State of California at the information in this statement of facts is true,
correct, and complete.
Signature: ____________________________
Date: ______________
For Office Use Only:
Travel time was verified via: ____Google Maps, ____ Metro.net, __Other: ___________________________
Amount of travel time granted: _______ minutes to activity, _______ minutes from activity
I attest this travel time is reasonable and therefore approve it: Staff initials: _____________ Date: ______________
3325 Wilshire Blvd., Suite 1100 ● Los Angeles, CA 90010 ● (213) 427-2700● Fax: (213) 427-2701
Request for Travel Time web form
Attn: ________________
Solicitud de Tiempo de Transporte
Nombre:___________________________ Numero de Caso: _____________
Para poder asistirle mejor con su cuidado de niños, necesitamos la siguiente
información:
Domicilio de proveedor:
______________________________________
domicilio
______________________________________
ciudad
(si hay mas de uno, indique):
código postal
______________________________________
domicilio
______________________________________
ciudad
Domicilio de actividad:
código postal
______________________________________
domicilio
______________________________________
ciudad
código postal
Su método de transportación (circule):
Carro
Autobús
Tren
Camino
Otro:
________________
La cantidad de tiempo de transporte que solicita del proveedor a actividad: _________ minutos
(cada dirección)
La cantidad de tiempo de transporte que solicita de la actividad al proveedor: _________ minutos
(cada dirección)
Por favor indique porque necesita esta cantidad de tiempo de transporte:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Yo declaro bajo pena de perjurio que, de acuerdo con las leyes de los
Estados Unidos de America y el Estado de California, que la información
en esta declaración es verdadera, correcta, y completa.
Firma: ____________________________
Fecha: ____________
Uso de Oficina Solamente:
Travel time was verified via: ____Google Maps, ____ Metro.net, __Other: ___________________________
Amount of travel time granted: _______ minutes to activity, _______ minutes from activity
I attest this travel time is reasonable and therefore approve it: Staff initials: _____________ Date: ______________
3325 Wilshire Blvd., Suite 1100 ● Los Angeles, CA 90010 ● (213) 427-2700● Fax: (213) 427-2701
Request for Travel Time web form