WWW.THESES.XLIBX.INFO
FREE ELECTRONIC LIBRARY - Theses, dissertations, documentation
 
<< HOME
CONTACTS



Pages:     | 1 |   ...   | 18 | 19 || 21 | 22 |

«Child Care and Development Fund Voucher Program Policy and Procedure Manual The Office of Early Childhood and Out of School Learning Family and ...»

-- [ Page 20 ] --

 My locally determined subsidy period expires;

 I have been convicted of CCDF fraud;

 I fail to honor a CCDF repayment agreement; and or  My child or children’s voucher(s) have been inactive for sixty (60) day.

DISCLOSURE STATEMENT:

18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious, or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.

Section 35-43-5-7: Welfare fraud(a) A person who knowingly or intentionally: (1) obtains public relief or assistance by means of impersonation, fictitious transfer, false or misleading oral or written statement, fraudulent conveyance, or other fraudulent means; (2) acquires, possesses, uses, transfers, sells, trades, issues, or disposes of: (A) an authorization document to obtain public relief or assistance; or (B) public relief or assistance; except as authorized by law; (3) uses, transfers, acquires, issues, or possesses a blank or incomplete authorization document to participate in public relief or assistance programs, except as authorized by law; (4) counterfeits or alters an authorization document to receive public relief or assistance, or knowingly uses, transfers, acquires, or possesses a counterfeit or altered authorization document to receive public relief or assistance; or (5) conceals information for the purpose of receiving public relief or assistance to which he is not entitled;

commits welfare fraud, a Class A misdemeanor, except as provided in subsection (b). (b) The offense is: (1) a Class D felony if: (A) the amount of public relief or assistance involved is more than two hundred fifty dollars ($250) but less than two thousand five hundred dollars ($2,500); or (B) the amount involved is not more than two hundred fifty dollars ($250) and the person has a prior conviction of welfare fraud under this section; and (2) a Class C felony if the amount of public relief or assistance involved is two thousand five hundred dollars ($2,500) or more, regardless of whether the person has a prior conviction of welfare fraud under this section. (c) Whenever a person is convicted of welfare fraud under this section, the clerk of the sentencing court shall certify to the appropriate state agency and the appropriate agency of the county of the defendant's residence: (1) his conviction; and (2) whether the defendant is placed on probation and restitution is ordered under IC 35-38-2.

I have read and understand the Penalties for Falsifying Information, as printed in this application. I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or contained in any communication supplying information to Family and Social Services Administration/Office of Early Childhood and Out of School Learning, or any deliberate alteration of any text on this application form, may be punished by criminal, civil, or administrative penalties including, but not limited to, the denial or revocation of CCDF benefits, and/or the imposition of fines, civil damages, and/or imprisonment.

Parent / Applicant Signature _______________________________________________________ Printed Name ____________________________________________ Date ____________________

ATTENTION! The income and residency documentation you submit must be dated no earlier than 30 days before the date you sign this worksheet.

–  –  –

Applicant/Co-Applicant _____________________________________ Previous Calendar Month __________________

Occupation ______________________________ Business Start-Up Date (mm/dd/yy) ___________________________

Business Name _____________________________________________ Are you licensed by the State? ___ Yes ___ No Business Address __________________________________________________________________________________

Are you registered with the Secretary of State (Indiana) ___ Yes ___ No Do you have an EIN number? ___ Yes ___ No Instructions: Use the table below to provide a statement of your profit/loss for the previous calendar month. Please provide revenue (money collected for the sale of your goods or service). You may consider any expense considered as such by the Internal Revenue Service (IRS) a legitimate expense for CCDF purposes.

Revenue Expense Profit/Loss

TOTAL REVENUE

For the Previous Calendar Month:

Expense:

Expense:

Expense:

Expense:

Expense:

Expense:

Expense:





Expense:

Expense:

Expense:

TOTAL EXPENSES

Profit/Loss (Revenue – Expenses)* PLEASE NOTE: You must also provide a copy of your IRS tax transcript (requested on IRS form 4506T-EX) for your most recently completed tax year, unless taxes have not been filed due to Business Start-Up Date.

As a new business (less than 8 weeks), I am requesting _______ hours per week of childcare to support my work activity.

By my signature below, I confirm the information provided is a true and accurate representation of my income. I understand I may be asked to provide documentation supporting revenue and expenses and agree to provide this information upon request.

Applicant Signature, ____________________________________________ Date ____________

(If there is a co-applicant working in this business, complete this section.) As a new business (less than 8 weeks), I am requesting _______ hours per week of childcare to support my work activity.

By my signature below, I confirm the information provided is a true and accurate representation of my income. I understand I may be asked to provide documentation supporting revenue and expenses and agree to provide this information upon request.

–  –  –

NOTE: Check stubs or employer’s cancelled checks (front and back) must be included with this form for the pay dates listed.

APPLICANT / CO-APPLICANT SECTION – To be completed by the employee.

I hereby authorize and request you provide the Child Care Development Fund information as specified below. This information is necessary to establish my eligibility for childcare assistance. This is without any liability to you whatsoever. You may retain a copy of this authorization for your records.

Employee Signature ___________________________________ Last 4 of Social Security Number ______________

Printed Name _______________________________Date________________Phone #_________________________

–  –  –

Is this individual still employed? ____ Yes ____ No If NO, please provide last day worked _______________________

Employer’s Name _____________________________________ Business Phone Number _________________________

Street Address _________________________________ City ____________________________ Zip ________________

Please provider your business’s EIN number ___________________________________ and/or attach your business card.

Signature _________________________________ Printed Name and Title ____________________________________

Date completed __________________ Note: This form cannot be accepted without the EIN number and/or business card.

If you have questions regarding this form, please contact

INSET LOCAL INTAKE INFORMATION HERE

CHILD CARE DEVELOPMENT FUND (CCDF) CHILD CARE VOUCHER PROGRAM

ALTERNATIVE WAGE DOCUMENTATION REQUEST v3-11-13 For purposes of CCDF eligibility, an Applicant and/or Co-Applicant must demonstrate a service and financial need.

Financial need is determined by calculating total income from all countable sources within the current period. If an Applicant or Co-Applicant is reporting employment as their service need, this must be documented by the receipt of earned income or wages. The following are appropriate sources to verify earned income or wages.

 Current pay stubs  A statement from The Work Number (an employer verification service), provided your employer participates  Copies of cancelled checks (front and back) and a completed CCDF Wage Detail Form If you are unable to provide the documentation listed above, you may submit a written request for consideration of other written documentation. Please complete the form below and return to your local intake office within 10 days of application termination.

–  –  –

You must attach copies of the following to your request: DO NOT SEND ORIGINAL DOCUMENTS A copy of your W2 or IRS form 1099 Any other relevant documentation to support your request

COMMENTS:

–  –  –

_____ Partnership – Partners Names ______________________________________

_____ Limited Liability Corporation incorporated in State of __________________

_____ Corporation incorporated in State of ________________________________

_____ Not For Profit type ______________________________________________

–  –  –

Your request will be reviewed by the Office of Early Childhood and Out of School Learning.

You will be notified within 10 calendar days of receipt of this request.

CHILD CARE and DEVELOPMENT FUND (CCDF) VOUCHER PROGRAM

TIPPED EMPLOYEE WORKSHEET (v7-16-12) Check Date: _________________________ Client Name: ___________________________________________

–  –  –

By my signature below, I confirm the information provided is a true and accurate representation of my income. I understand my employer may be asked to provide additional information supporting my declarations above and provide my consent for wage verification.

Applicant/Co-Applicant Signature _________________________________________ Date: _______________________

Employer Name: ________________________________________________ Phone: ____________________________

–  –  –

General Instruction:

A. Paystubs or a CCDF approved alternative is required in addition to the Tipped Wages Worksheet.

B. If you are unable to determine which categories are included in your gross wages or if the hours reflected on your pay stub are not accurate, you MUST obtain a signed and dated statement from your employer and submit with the Tipped Wages Worksheet.

(The statement must be on company letterhead or include business card from individual signing statement or provide the Tax Identification Number of your employer.)

–  –  –

Applicant or Co-Applicant Name _______________________________________ Case Number __________ Last Date Worked or Attending School__________________________________________________________

Please read an initial each of the following statements acknowledging your understanding of the job search requirements.

__________ I understand I am eligible for a maximum of thirteen (13) weeks of job search in a twelve (12) month period if I become lose my service need. Childcare during job search is based on my previous authorized child care amounts and may not be increased.

__________ I understand I may be required to provide proof of my job search activities, and therefore, agree to maintain documentation of these activities.

__________ I understand childcare services provided during job search are dependent on my participating in job search activities.

I understand failure to complete these activities may result in my requirement to repay childcare paid on my behalf.

–  –  –

I understand my job search assistance will end on _____________________. I must obtain an appointment with the intake office by this date to review my employment status or my childcare will be terminated without further notice. Should I obtain employment prior to this date, I must contact the intake office and provide proof of employment within ten (10) days.

Signed, _________________________________________________ Date __________________

NOTE: THIS FORM MUST BE SUBMITTED WITH PROOF OF LAST DAY OF WORK OR SCHOOL, UNLESS YOU

ARE NEW MEMBER OF THE CCDF HOUSEHOLD, WHICH COULD INCLUDE, IF EMPLOYED:

LAST PAY STUB

SIGNED STATEMENT FORM EMPLOYER INCLUDING TERMINATION DATE

TERMINATION NOTICE

VERIFICATION OF CLAIM FOR UNEMPLOYMENT

COPY OF YOUR LETTER OF RESIGNATION OR BUSINESS/TRADE END DATE

IF IN SCHOOL:

DIPLOMA OR CERITFICATEOF COMPLETION

SIGNED STATEMENT FROM SCHOOL INCLUDING DATE OF COMPLETION

DOCUMENTATON OF WITHDRAWAL

PREVIOUS SEMESTERS GRADES OR TRANSCRIPT

SCHOOL SCHEDULE FROM MOST RECENT SEMESTER WITH CURRENT PRINT DATE

IF IN APPROVED LEAVE:

WRITTEN REQUEST FOR JOB SEARCH

This letter is to be used to provide an applicant to opportunity to utilize job search to off-set a repayment.

It should be prepared on Intake letterhead.

Date of Notice

Dear Applicant or Co-Applicant:



Pages:     | 1 |   ...   | 18 | 19 || 21 | 22 |


Similar works:

«Blackpool Safeguarding Adults Board Multi-Agency Safeguarding Policy & Procedures This document is divided into three parts – Part One – Policy This section of the document provides the scope and guiding principles of the procedures, definitions. Part Two– Procedures This section describes the actions required of individuals and organisations to respond to suspected or actual abuse of an adult at risk. Actions within the procedures should be informed by the policy. Part three Guidance...»

«THE SOUTHERN AFRICAN MIGRATION PROJECT CROSS-BORDER RAIDING AND COMMUNITY CONFLICT IN THE LESOTHO-SOUTH AFRICAN BORDER ZONE MIGRATION POLICY SERIES NO. 21 CROSS-BORDER RAIDING AND COMMUNITY CONFLICT IN THE LESOTHO-SOUTH AFRICAN BORDER ZONE GARY KYNOCH AND THERESA ULICKI WITH TSEPANG CEKWANE, BOOI MOHAPI, MAMPOLOKENG MOHAPI, NTSOAKI PHAKISI AND PALESA SEITHLEKO Published by Idasa, 6 Spin Street, Church Square, Cape Town, 8001, and Queen’s University, Canada. Copyright Southern African...»

«CHAPTER 5 The Underlying Assumptions, Theory, and Practice of Neoliberal Land Policies Saturnino M. Borras Jr. In the early 1990s, neoliberal land policies emerged within, and became an important aspect of, mainstream thinking and development policy agendas. These policies have increased in prevalence since their inception at the end of the Cold War. They deal with both public and private lands, and have manifested in four broad policy types: (1) privatization and individualization of...»

«golby + luck landscape architects Green Pits Lane, Nunney Landscape & Visual Appraisal Client: Barratt Homes Bristol Date: January 2014 Ref: GL0159 Tel: 01530 265688 Web: www.golbyandluck.co.uk Email: info@golbyandluck.co.uk R eg i s te red O f fi ce: 20 7 L ei ce s te r Road, I bs toc k, Le ic es ter sh i re, LE67 6 HP Gol by and Luc k LLP (Par tnership No. OC3823 74) Re gistered in E ngl and and Wal es Green Pits Lane, Nunney Landscape & Visual Appraisal Client: Barratt Homes Bristol...»

«The Law Commission (LAW COM No 360) PATENTS, TRADE MARKS AND DESIGNS: UNJUSTIFIED THREATS Presented to Parliament pursuant to section 3(2) of the Law Commissions Act 1965 Ordered by the House of Commons to be printed on 12 October 2015 HC 510 © Crown copyright 2015 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information...»

«Case Study Approach Examining Local Wellness Policy Development and the Perceived Impact to the School Community National Food Service Management Institute The University of Mississippi 1-800-321-3054 This publication has been produced by the National Food Service Management Institute – Applied Research Division, located at The University of Southern Mississippi with headquarters at The University of Mississippi. Funding for the Institute has been provided with federal funds from the U.S....»

«Policy Template Guide Sample Policies for Transition Houses, Second Stage Housing and Safe Homes March 2015 BCSTH Policy Template Guide Table of Contents Overview Program Policy Templates 1.0 Equality and Diversity Part A: Dependents Part B: Women under the age of 19 Part C: Inclusivity 1.2 Client Rights 1.3 Length of Stay 1.4 When a Request for Housing or Shelter cannot be Accommodated 1.5 Second Stage Housing Tenant Rent Contribution Part A: Tenant Income Part B: Tenants on Income Assistance...»

«ACCREDITATION POLICY AND PROCEDURE MANUAL Effective for Evaluations During the 2008-2009 Accreditation Cycle Incorporates all changes approved by the ABET Board of Directors as of November 3, 2007 Applied Science Accreditation Commission Computing Accreditation Commission Engineering Accreditation Commission Technology Accreditation Commission ABET, Inc. 111 Market Place, Suite 1050 Baltimore, MD 21202 Telephone: 410-347-7700 Fax: 410-625-2238 E-mail: accreditation@abet.org Website:...»

«THE CAMPAIGN FOR BOSTON UNIVERSITY GIFT POLICY and CREDITING MANUAL May 2012 The Campaign For Boston University Gift Policy Manual Table of Contents Page I. INTRODUCTION Definitions of Support 3 II. MAKING A GIFT TO BOSTON UNIVERSITY Gift Types 4 Methods of Giving 5-6 Fund Types 7 III. SOLICITING GIFTS ON BEHALF OF BOSTON UNIVERSITY General Policies 8 Policies Specific to Annual Giving 8 Raising Funds from Events 9 IV. GIFT ACCEPTANCE POLICES General Principles 9 When a Gift Should Not Be...»

«DIRECTORATE GENERAL FOR INTERNAL POLICIES LEGAL AFFAIRS Legal aspects of free and open source software COMPILATION OF BRIEFING NOTES This document was requested by the European Parliament's Committee on Legal Affairs.RESPONSIBLE ADMINISTRATORS Danai PAPADOPOULOU Policy Department C: Citizens' Rights and Constitutional Affairs European Parliament B-1047 Brussels E-mail: danai.papadopoulou@europarl.europa.eu Rosa RAFFAELLI Policy Department C: Citizens' Rights and Constitutional Affairs European...»

«HUDSON INSURANCE COMPANY ARCHITECTS, ENGINEERS & ENVIRONMENTAL SERVICES PROFESSIONAL LIABILITY INSURANCE POLICY This is a Claims Made and Reported Policy. Please Read it Carefully. All words that are in bold face type have special meaning set forth in Section V., DEFINITIONS, of this Policy. Throughout this Policy, the words, you and your refer to the Named Insured shown in the Certificate of Declarations and any other individual or entity qualifying as an Insured under this Policy. The words...»

«Guidance on uniforms and work wear Contents Introduction General principles Organisational requirements Legal requirements Moving and handling of patients Infection prevention and control issues Minimum organisational standards Developmental standards Minimum professional and personal standards Suggested content for uniform and work wear policy/guidance Tax relief Nursing students Bank and agency staff References and further reading Note: This guidance sets out principles that are applicable to...»





 
<<  HOME   |    CONTACTS
2016 www.theses.xlibx.info - Theses, dissertations, documentation

Materials of this site are available for review, all rights belong to their respective owners.
If you do not agree with the fact that your material is placed on this site, please, email us, we will within 1-2 business days delete him.