Name of child / National ID No.
Name of child / National ID no.
Name of child / National ID No.
Name of child / National ID No.
Address / Telephone
Mother/wife/cohabitor / National ID No.
Employer / Work tel.no.
Father/husband/cohabitor / National ID No.
Employer / Work tel.no.
Monthly income
As of (date) / The woman / The man
Taxable gross pay (including holiday pay) plus value of taxable benefits / 0 / SEK / SEK
Taxable remuneration from the Swedish Social Insurance Agency and the Unemployment Fund / SEK / SEK
Pension and annuity / SEK / SEK
Childcare allowance for the portion representing the fee / SEK / SEK
Family allowance in the case of national service training and refresher training / SEK / SEK
Foster care allowance (the portion representing the fee) / SEK / SEK
Total SEK/month / SEK / SEK
Further information
Other children in the family who are placed in private childcare
Name of child / National ID No.
Name of child / National ID No.
Signature
Place and date
Signature of mother/wife/cohabitor / Signature of father/husband/cohabitor
The personal details provided above will be registered with the Municipal Authority and treated in accordance with the rules and regulations of the Personal Data Act (SFS 1998:204).
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Laholm Municipality, Issue3, July 2011
Information
1. The fee payable for childcare is based on total monthly gross income. Please note: This also applies to cohabitors who are not the biological parents. Once you have been offered a childcare place for your child/children, you must enter your income details on this form without delay. You must provide these details before your child fills the place offered.
2. Please hand in this form to your preschool/leisure-time centre or family day care provider. You can also send this form to:
Laholms kommun
Humlegången 6
312 80 LAHOLM
3. If you do not provide your income details, you will be charged at the maximum rate for the highest fee. After you have provided your income details, the fee will then be adjusted at the end of the same month. No arrears adjustment will be made.
4. If your income is adjusted, you must straight away and without being asked inform us of this adjustment.
5. At the request of the Municipal Authority's auditors, we will also continue to check the income details provided.
In order to avoid your being charged the wrong amount,
please provide your income details.