Name of EY provision
Provision phone number
Ofsted number / Unique reference number (URN)
Term dates for setting – when are you open? (DD/MM/YY – DD/MM/YY)
Legal surname of child
Legal first name of child
Date of birth / Gender
Ethnicity (Please select from list on reverse)
Home address
Postcode
Please delete as appropriate: /
New Starter/Continuing Adjustment
Child’s funded start date this term / date hours increased from if an adjustment
Parental declaration form completed and signed by parent / carer / Yes / No
Number of whole FF2 weeks claimed / weeks remaining if an adjustment
(Maximum 14 term time or 17 stretched) / Stretched / Yes / No
Number of FF2 hours claimed per week/ additional hours if an adjustment
(Maximum 15 term time or 12 stretched)
Amount due
£5.02 x weeks attended x hours claimed
Wraparound hours per week (over and above the FF2 hours claimed)
Total hours attended per week
Name of person responsible for FF2 / Date
Please print name above or type if returning by email

Payment of Claim

-  Your claim will be paid at the rate of £5.02 per hour

-  Payment can only be processed when the eligibility of the family has been confirmed

-  Funding will be paid from the start of the week during which eligibility has been confirmed and

once a child has taken up their free place

All early years providers are required by the Department for Education to collect information on a child’s ethnic background. Please select the child’s ethnicity from the list below and enter into the “Ethnicity” box on the front of this claim form. This should match the child’s ethnicity recorded on the parental declaration form. Parents have the right to refuse to give this information.

White

English / Greek Cypriot
Scottish / Gypsy
Welsh / Roma
Cornish / Other Gypsy/Roma
Other White British / Kosovan
Irish / Portuguese
Traveller of Irish Heritage / Turkish
Albanian / Turkish Cypriot
Bosnian-Herzegovinian / White Eastern European
Croatian / White Western European
Greek / White Other

Asian or Asian British

Indian / Sri Lankan Sinhalese
Pakistani / Sri Lankan Tamil
Bangladeshi / Sri Lankan Other
African Asian / Other Asian
Nepali

Mixed/Dual Background

White/black Caribbean / Asian/Other
White/black African / Black/Other
White/Pakistani / Chinese/Other
White/Indian / White/Any Other
White/Any other Asian background / Other mixed background

Black or Black British

Caribbean
African
Any other black background

Chinese

Chinese

Any Other Ethnic Group

Afghan / Latin/South/Central American
Arab other / Lebanese
Egyptian / Malay
Filipino / Thai
Iranian / Vietnamese
Iraqi / Any other ethnic group
Japanese / Refused
Kurdish