EDUCATION PROVIDER CLAIM FOR REIMBURSEMENT FROM DIVORCING PARENT EDUCATION AND MEDIATION FUND (T.C.A. § 36-6-413) FOR REDUCED FEE PARENTING EDUCATION INSTRUCTIONS: Type and submit in duplicate to the Administrative Office of the Courts, Programs Manager, Divorcing Parent Education and Mediation Fund, 511 Union Street, Suite 600, Nashville, TN 37219. STATE OF TENNESSEE COUNTY OF: ________________________________ COURT: ______________________________ PART: ___________________ Cases for which a claim is being made: Docket No. Name of Parent Date of Referral Date of Service Totals: Service Fee $ Material Fee $ NOTE: Attach copies of the original Orders to No Fee or Reduced Fee Education to this form. Give details of the parenting education services and material provided in the area provided on the back of this form. I certify that the foregoing represents an accurate, complete statement of time in connection with parent education in the above action or proceedings. Enter FULL Name, Address, and Phone Number __________________________________________________ Signature of Education Provider Date Address: _____________________________________________ Provider: ____________________________________________ _____________________________________________________ Tax I.D. No.: __ __ __ - __ __ - __ __ __ __ City: ___________________ State: _____ Zip: _____________ Phone: ( __ __ __ ) __ __ __ - __ __ __ __ TO BE COMPLETED BY THE ADMINISTRATIVE OFFICE OF THE COURTS Total authorized payment ............................................................ $___________________________ Education Provider Claim Form 9/05 1 of 2 American LegalNet, Inc. www.USCourtForms.com Date of Service Name of Parent Education Provider Claim Form 9/05 Services Provided Materials Provided 2 of 2 American LegalNet, Inc. www.USCourtForms.com