Nottinghamshire Children,
Families and Cultural Services
EARLY YEARS 2, 3 & 4 YEAR OLD FUNDED ENTITLEMENT
PARENTAL DECLARATION FORM
1. CHILD DETAILS
Legal or Given First Name: Chosen or Preferred First
Name:
Legal or Given Middle Chosen or Preferred Middle
Name(s): Name(s):
Legal or Given Surname: Chosen or Preferred
Surname:
Date of Birth dd/mm/yyyy / / Gender (please tick) M F
Proof of DoB Type Seen Proof of DoB Witnessed by Date:
(eg Birth Certificate, (staff member name):
Passport):
Home Address: Previous Home Address: (if
you have moved house in
the last 6 months)
Postcode: Previous Postcode:
Additional Information ** EHCP LAC Adopted Residence Order / Special Guardianship
** If you have ticked any of the above your Provider may ask you to produce evidence
(Definitions: EHCP: Education, Health and Care Plan; LAC: Looked After Child)
ETHNICITY of child
Please indicate your child’s ethnicity: (if you do not wish to tell us please tick ‘prefer not to say’)
WHB White British BLB Caribbean AAO Any other Asian background
WHR White Irish BLF African CHE Chinese
WHA Any other white background BLG Any other Black background OEO Any other ethnic group
MWA White and Asian ASR Sri Lankan WHT Irish Heritage
MWB White and Black Caribbean AIN Indian WRO Roma/Roma Gypsy
MBA White and Black African APK Pakistani WHO Any other Traveller
background
MOT Any other mixed background ABA Bangladeshi REF Prefer not to say
2. PARENT/CARER DETAILS (below must be completed where a child is claiming 30 Hours or Two Year Funding)
If you wish to claim for 30 hours we need your written consent to validate your code. We can’t validate the code
without your own date of birth and your NI/NASS number so please complete all boxes in this section; please
also sign the box below and the main declaration on the reverse of this form to indicate your consent.
If you believe that your child may qualify for Early Years Pupil Premium (see General Information for Parents
sheet) please provide the following information for the main benefit holder to enable the local authority to
confirm eligibility.
Parent/Carer First Name: Parent/Carer
Surname:
Parent/Carer Date of Birth: Parent/Carer
National Insurance
Number or National
Asylum Support Service
(NASS)
Number:
Parent/Carer
Signature:
3. ELIGIBILITY CODES (below must be completed where a child is claiming 30 Hours or Two Year Funding)
30 Hours Eligibility Two Year Old Funding
Code (e.g 5000123456) (TYOF) Reference Number
(or copy of Eligibility letter
attached)
4. DISABILITY ACCESS FUND DECLARATION
Is your child eligible and in receipt of Disability Living Allowance (DLA)? Yes No
Please tick as appropriate:
If your child is splitting their Funded Entitlement across two or more
providers please
nominate the main setting where the local authority should pay the DAF:
5. FUNDED ENTITLEMENT CLAIM DETAILS
The table below is to be completed with details of your child’s Funded Entitlement claim at this early year’s
provider. You must also declare below ALL Funded Entitlement hours that are claimed by your child at all
other providers you are using.
Your child can attend a maximum of two sites in a single day
A maximum of 10 hours can be claimed in any one day
Funded Entitlement hours are funded for equivalent of 38 weeks of the year:
I.e. maximum funding of 570 hours per year for 15 hrs/wk or maximum of 1140 hours per year (30 hrs/wk).
Please ensure that you specify below the provider(s) that is/are to receive your UNIVERSAL 15 hours of
Funded Entitlement - please tick against each setting which is to receive this. This is only applicable if you are
claiming 30 hours Funded Entitlement
If you are claiming 30 hours Funded Entitlement, you must complete sections 2 and 3 (overleaf) with your
name, your own date of birth, your NI/NASS Number and 30 Hours Eligibility Code
If you are claiming Two Year Funding, you must complete sections 2 and 3 (overleaf) with your name, your
own date of birth, your NI/NASS Number and TYOF Reference Number
Name of Provider who
has issued this form
Start Date of Funded End Date of Funded Hours
Hours: (if known):
Universal Please enter total Funded Entitlement
Hours? Hours claimed per day at each
setting
Tick against Total Number
Names of all childcare
ALL settings Number of Weeks
providers currently
this applies to. of Hours Claimed
used (including the
Must not Claimed per Year
provider who has Mon Tue Wed Thu Fri
exceed more per (e.g 38,
issued this form)
than 15 hours Week 45,
per week 52)
I wish to claim the following number of hours per week at this provider for the child
mentioned in Section 1 of this form (max 30 hours):
6. DECLARATION
Parent/Carer Name:
I can confirm that I have read and understood the form and
that the information I have provided above is accurate and
true. I understand and agree to the conditions set out in
this document and I authorize the provider (as confirmed in Parent/Carer
Section 5) to claim Funded Entitlement as agreed above on Signature:
behalf of my child.
In addition, I give permission for Nottinghamshire County Date of Signing:
Council to check my eligibility status with government
departments and hold my details to make further checks
for pupil benefits including Early Years Pupil Premium
(EYPP) or Disability Access Fund (DAF) or Free School Meals Setting Name:
when my child is at an eligible age. I agree that the
information I have provided can be shared with the Local
Authority and Department for Education, who will access
information from other government departments to confirm Setting Signature:
my child’s eligibility and enable this provider to claim on
behalf of my child. I agree that the information on this form
can be shared locally for the benefit of my family. Date of Signing:
I also consent to allow the Local Authority to hold personal
data to support pupil’s learning and monitor and report on
their progress as per our Privacy Notice (obtainable from
your childcare provider).
Notes for provider:
If a parent has a Two Year Old Funding letter from another authority, please attach a copy to this form. We may
ask to see this as evidence of eligibility.
Providers are required to retain this completed form within the setting. Please do not send them to us. You will need
the information contained on the form to complete your portal headcount returns. If there are any changes to the
information contained in this form e.g. hours attended by child, you should ensure that the parent/carer completes
a new form. Any subsequent forms should also be retained by the setting.
