Payment Discrepancy Form - 4CS of Passaic County 2026

The document outlines the procedures and forms related to attendance logging and payment discrepancies for child care services under the New Jersey Department of Human Services. It includes an ECC Attendance Log for tracking children's attendance, requiring signatures from both parents and providers, and a Provider Payment Discrepancy Form for reporting issues with payments. The forms are specific to Passaic County and emphasize the importance of accurate record-keeping in the ECC system.

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Click ‘Get Form’ to open the Payment Discrepancy Form in our editor.
Begin by entering the county name, which is Passaic, and the date of submission at the top of the form.
Fill in your name as the provider and include your EPPIC ID number along with your address and telephone number.
Indicate if you have a new address or phone number by selecting 'Y' or 'N'.
Select whether you are a POS User or IVR User by checking the appropriate box.
List each child’s name, ID, and the dates for which you were not paid accurately. Specify if they are Full-Time (FT) or Part-Time (PT).
Provide any comments regarding payment discrepancies, including amounts paid if applicable.
Sign and date the form at the bottom to certify accuracy before submitting it to your CCR&R.

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