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



Pages:     | 1 |   ...   | 19 | 20 || 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 21 ] --

As stated on the enclosed documents, your failure to report the loss of your CCDF approved service need has resulted in child care benefits being paid for care provided to your child(ren) which were ineligible. The enclosed Parent Repayment represents ____ weeks of child care benefits.

According to our records, you were eligible for ____ weeks of job search in a 12 month period beginning one day after loss of your CCDF approved service need. The Family and Social Service Administration (FSSA) is providing you the opportunity to report any job search activities you conducted during your lapse in service need.

If you wish to utilize any available job search time to reduce the amount of your Parent Repayment, you must complete and return the form no later than (insert date 10 days from notice). Your Parent Repayment will then be recalculated to reflect the use of job search.

PLEASE NOTE: Your job search eligibility will be reduced and/or exhausted for the next 12 months. Should you lose your CCDF approved service need within the next 12 months, you must report the loss within 10 days or you will be subject to repayment of all or part of the ineligible child care benefits.

–  –  –

Name: ____________________________________________________ County: ________________

I wish to use _______________ weeks of job search to reduce the amount of my Parent Repayment.

During these weeks I was doing the following job search activities (examples: interviews, research, etc.) ____________________________________ ____________________________________

____________________________________ ____________________________________

____________________________________ ____________________________________

By my signature below, I acknowledge I may not be eligible to utilize job search as my CCDF approved service need for a period of 12 months. I understand it is my responsibility to report the loss of my CCDF approved service need to the CCDF Intake Office within 10 days of the loss.

Signature___________________________________________________ Date ______________________________

CHILD CARE and DEVELOPMENT FUND (CCDF) VOUCHER PROGRAM

NAME ATTESTATION (v5-20-12) Individual’s Name _________________________________ Applicant Co-Applicant The name above should be recorded as it appears on the CCDF Application (State Form 805)

is also known as:

List any other names, including those on documents provided, the Applicant or Co-Applicant is using or has used.

_______________________________________________________ (Printed Name) _______________________________________________________ (Printed Name) _______________________________________________________ (Printed Name) and that all names listed above are the same person.

I hereby affirm, under the penalties of perjury, I am the above named individual and I have personally prepared the foregoing statement for myself and the same is true to the best of my knowledge and belief.

Signature of Individual _________________________________________ Date _____________

NOTE: This document shall be used when the Applicant or Co-Applicant’s name does not match all sources of verification information provided to the Intake Agent.

CHILD CARE and DEVELOPMENT FUND (CCDF) VOUCHER PROGRAM

CHILD SUPPORT AND MAINTENANCE DECLARATION (v10-14r) Declare below, by child, the average amount of child support received MONTHLY, if received in the previous 30 days.

–  –  –

1. $ 2 $ 3. $ 4. $ 5. $ 6. $ 7. $

–  –  –

By my signature below, I hereby certify all the information provided is true and correct to the best of my knowledge. I understand I may be requested to verify this statement and give my consent to the agency from where I am requesting services to make any necessary contacts to verify any statement. I understand my deliberate failure or misrepresentation of any information in this statement may result in my inability to participate in the Child Care and Development Fund (CCDF) Voucher Program.

Signature __________________________________________________ Date ___________________________

CHILD CARE and DEVELOPMENT FUND (CCDF) VOUCHER PROGRAM

SECONDARY SCHOOL ENROLLMENT VERIFICATION (v10-14) By my signature below, I give consent to __________________________ to release my enrollment information to the CCDF Intake Office listed below. This information is necessary to establish my eligibility for child care assistance.

Student (CCDF Applicant) Signature _______________________________________________

Printed Name ______________________________________ Date _____________________

For School Use Only:

Student’s Street Address: ___________________________________________________________

Student’s City _________________________________ Student’s Zip Code ________________

Student’s Current Grade Level _________________ Anticipated Graduation Date ____________

–  –  –

School Name: ____________________________________________________________________

School Address: __________________________________________________________________





Phone: _____________________________________ Fax: ________________________________

Completed by: ______________________________________ Date _________________________

Printed Name: ______________________________________ Title _________________________

–  –  –

We have read and understand the above statements. Our signatures on this form acknowledge our compliance.

____________________________________ ___________________________________ _______________

Parent/Step-Parent/Guardian Name (Printed) Parent/Step-parent/Guardian Signature Date ____________________________________ ___________________________________ _______________

Please print Facility Name (Employer) Facility Owner/Director Signature Date If the Provider (Employer) is a CCDF Eligible Licensed Child Care Home, the parent/step-parent/guardian MAY NOT work at the home where their child attends. (CCDF Policy 2.11.4) Parent’s work site address/ license #____________________________________________________

Child name(s)______________________________________________________________________

Child attends site address/license # _____________________________________________________

Child name(s)______________________________________________________________________

Child attends site address/license # _____________________________________________________

_____________________________________ __________________________________ _______________

Parent/Step-parent/Guardian Printed Name Parent/Step-parent/Guardian Signature Date _____________________________________ __________________________________ _______________

Provider (Employer) Printed Name Provider (Employer) Printed Name Date DETERMINING CHILDCARE NEED (v2-16)

–  –  –

Case Name___________________________________________ Case Number_____________________

Co-Applicant Cardholder Name ___________________________________________________________

(A) New Applicant □ Applicant □ Co-Applicant Reason for Issuance (check all that apply) (B) Replacement □ Lost/stolen □ Not working □ Other ______________

By signing this form, I am acknowledging I have received this HOOSIER WORKS FOR CHILD CARE CARD and understand the policies related to its use.

 I understand I may not allow anyone, including my child care provider, to possess or use my Hoosier Works for Child Care card to authorize electronic attendance transactions for child(ren).

 I understand a provider should never attempt to force me to violate this policy. If a provider does attempt to force me to violate this policy, I shall immediately report it to the Local Intake Agent for referral to the state.

 Exceptions to this policy will only be accepted with written documentation from the Office.

Failure to follow the above policy could lead to negative action taken against me and/or my child care provider, up to and including termination from the Child Care and Development Fund (CCDF) voucher program.

 I have received the HOOSIER WORKS FOR CHILD CARE CARD.

 My card will be mailed, when my application is processed if I have valid vouchers Applicant or Co-Applicant Signature ________________________________________Date ______________

–  –  –

Case Name___________________________________________ Case Number_____________________

The Individual below is approved to receive a HOOSIER WORKS FOR CHILD CARE CARD.

First Name____________________ MI_____ Last Name_________________________ DOB ________ Address ______________________________________________ Phone _________________________

(B) Replacement □ Lost/stolen □ Not working □ Other _______________

Reason for Issuance (Check all that apply) (C) Authorized Representative / Relationship to Applicant _________________

Type of ID seen ______________________________________________________________________

(One picture ID or two other forms of ID, one of which must contain a signature) By signing this form, I am acknowledging I have received this HOOSIER WORKS FOR CHILD CARE CARD and understand the policies related to its use.

 I understand I may not allow anyone, including my child care provider, to possess or use my Hoosier Works for Child Care card to authorize electronic attendance transactions for child(ren).

 I understand a provider should never attempt to force me to violate this policy. If a provider does attempt to force me to violate this policy, I shall immediately report it to the Local Intake Agent for referral to the state.

 Exceptions to this policy will only be accepted with written documentation from the Office.

Failure to follow the above policy could lead to negative action taken against the Applicant and Co-Applicant and/or the child care provider, up to and including termination from the Child Care and Development Fund (CCDF) voucher program.

 I have received the HOOSIER WORKS FOR CHILD CARE CARD.

 My card will be mailed, when my application is processed if I have valid vouchers Cardholder Signature_______________________________________________ Date ___________________

AUTHORIZATION FOR AN AUTHORIZED USER

I, the Applicant for CCDF benefits, am requesting _____________________________ to be designated as an authorize user for my HOOSIER WORKS FOR CHILD CARE CARD. I acknowledge the user of this card is acting as my representative and as such I am responsible for attendance documented by my authorized user, even if such attendance is erroneous. Further, I understand I may revoke this agreement at any time by providing written notification to the local Intake Agent.

–  –  –

16 Digit Card Number ______________________________________ _____ Video & verbal/written (Or a copy of the front of the HW card issued.)

–  –  –

Nature of non-compliance, i.e. failure to report change in household size, failure to report loss of service need, card found in provider’s possession, improper payment for personal day, etc...

–  –  –

PARENT AFFIRMATION SECTION

By my signature below, I acknowledge this non-compliance has been explained fully and I have received the following:

 Repayment Appeal Procedures, if applicable  A copy of this completed Parent Non-Compliance Form  A copy of my signed Parent Rights and Obligations Form I agree to abide by all CCDF Policies. I understand a future CCDF policy non-compliance may result in the termination of my child care benefits.

Parent was not present. All attachments were mailed. Intake Name and Date ______________________________________________

Signed: ___________________________________________________________ Dated: _________________________________

This letter is to accompany any Parent Repayment Agreement. V10-2-12 Date Applicant Name Applicant Street Applicant City, State Zip Code Dear Applicant;

A review of your case has resulted in a finding of non-compliance with your CCDF Parent Obligations as stated on the enclosed Parent Non-Compliance form. Additionally, this non-compliance may have resulted in child care benefits paid for care provided to your child(ren) which were ineligible due to the non-compliance. If ineligible child care benefits were paid, the Family and Social Service Administration (FSSA) is seeking repayment as stated on the enclosed CCDF Parent Repayment form.

On the enclosed Parent Repayment Form, please indicate if you would like to make a lump sum payment or prefer to make the stated monthly payment until the balance owed is paid in full. Then sign the form and return it to the address listed. Directions for submitting your payment are included on this form as well.

If you do not agree with this repayment determination, steps for appealing the decision are also enclosed.

Failure to successfully appeal or to make repayment in full will result in FSSA taking any and all available means of collection including, but not limited to, tax intercept.

Sincerely,

–  –  –

DISPUTE OF REPAYMENT AGREEMENT

My signature below acknowledges I am not in agreement with the determination of an overpayment and have opted to appeal this determination. I have been provided a copy of the Repayment Appeal Procedures and understand I must file a written appeal within 30 calendar days according to the Repayment Appeal Procedures. My failure to contest the overpayment within 30 calendar days from the date of this document deems the overpayment determination to be correct which may result in my termination from the CCDF voucher program and other collection attempts as appropriate.

–  –  –

Nature of non-compliance, i.e. failure to report change in household size, failure to report loss of service need, card found in provider’s possession, improper payment for personal day, etc...



Pages:     | 1 |   ...   | 19 | 20 || 22 |


Similar works:

«U.S. Citizenship and Immigration Services Office of the Director (MS 2000) Washington, DC 20529-2000 March 8, 2016 PM-602-0130 Policy Memorandum SUBJECT: Eligibility for Employment Authorization for Battered Spouses of Certain Nonimmigrants Revisions to the Adjudicator’s Field Manual (AFM); Revision of Chapter 30.13 (AFM Update AD16-01) Purpose This policy memorandum (PM) provides guidance to U.S. Citizenship and Immigration Services (USCIS) officers regarding the amendment to the Immigration...»

«10 STEPS FOR INTEGRATING GENDER INTO THE POLICY-MAKING PROCESS Gender mainstreaming, by definition, involves integrating a gender perspective and gender analysis into all stages of designing, implementing and evaluating projects, policies and programmes.The 10 Steps for Gender Mainstreaming include: 1. A Mainstreaming Approach to Stakeholders: Who are the Decision-Makers? 2. Mainstreaming a Gender Agenda: What is the Issue? 3. Moving Towards Gender Equality: What is the Goal? 4. Mapping the...»

«PREMIER TABLES & LOUNGES GUIDLINES 2015-2016 TABLE OF CONTENTS I. STAPLES Center General Information Important Telephone Numbers Directions to STAPLES Center STAPLES Center Concourses o Public Concourses o Private Concourses o Map of Main Concourse o Map of Upper Concourse o Map of Suite Level A Premier Table & Lounge Benefits Wells Fargo ATMs Wells Fargo Conference Center Box Office o AXS Event Suites First Aid Stations Guest Link Service Centers Guests with Disabilities Merchandise Security...»

«Revisiting Policy Design: The Rise and Fall (and Rebirth?) of Policy Design Studies Michael Howlett Department of Political Science Simon Fraser University Burnaby BC Canada V5A 1S6 Paper Prepared for the General Conference of the European Consortium for Political Research (ECPR) Section 63 Executive Politics and Governance in an Age of Multi-Level Governance Panel 52: Policy instruments: choices and design Panel Session: 7 Friday, 26 August, 1500-1640 University of Iceland Reykjavik, Iceland...»

«TOURISM POLICY MAKING: THE POLICYMAKERS’ PERSPECTIVES Nancy Stevenson University of Westminster, U.K. David Airey, University of Surrey, Faculty of Management and Law, U.K. Graham Miller, University of Surrey, Faculty of Management and Law, U.K.ABSTRACT This research explores tourism policy making, from the perspectives of policy makers using grounded theory. It focuses on Leeds, a city in the North of England, which is characterized by its turbulent environment. The paper identifies themes...»

«Getting out and about: Investigating the impact of concessionary fares on older people’s lives A study by the Transport Action Group – Manchester Authors: Emily Hirst and Bill Harrop July 2011 Getting out and about: Investigating the impact of concessionary fares on older people’s lives A study by the Transport Action Group – Manchester Authors: Emily Hirst and Bill Harrop. Preface The Transport Action Group This study was initiated through the Transport Action Group – Manchester...»

«Assessment in Inclusive Settings Key Issues for Policy and Practice European Agency for Development in Special Needs Education The production of this document has been supported by the DG Education, Training, Culture and Multilingualism of the European Commission: http://europa.eu.int/comm/dgs/education_culture/index_en.htm This report was edited by Amanda Watkins, Agency Project Manager, on the basis of contributions from the Agency's Representative Board members, National Coordinators and...»

«UNIVERSITY OF PITTSBURGH POLICY 11-02-02 CATEGORY: RESEARCH ADMINISTRATION SECTION: Technology Management SUBJECT: Copyrights EFFECTIVE DATE: September 5, 2006 Revised PAGE(S): 7 I. SCOPE In the course of teaching, research and other scholarly and administrative activities at the University, faculty, staff, postdoctoral associates, students and others may create works that are protected by copyright. Federal Copyright Law provides protection for original works of authorship automatically at the...»

«The Uncounted Hours: The Perception of Women in Policy Formulation S. June Menzies* I. Introduction The Speech from the Throne opening the Second Session of the 29th Parliament (February 27, 1974) announced the government's objective of creating a society free from discrimination.' This is an elusive goal, particularly where one is aiming at a society free from discrimination on the basis of sex. In 1970 the Royal Commission on the Status of Women made one hundred and sixty-five recommendations...»

«WPS5370 Public Disclosure Authorized Policy Research Working Paper 5370 Public Disclosure Authorized Child Ability and Household Human Capital Investment Decisions in Burkina Faso Richard Akresh Public Disclosure Authorized Emilie Bagby Damien de Walque Harounan Kazianga Public Disclosure Authorized The World Bank Development Research Group Human Development and Public Services Team July 2010 Policy Research Working Paper 5370 Abstract Using data they collected in rural Burkina Faso, the in...»

«Change of Ownership American General Life Insurance Company The United States Life Insurance Company in the City of New York A member of American International Group, Inc. (AIG) In this form, the Company refers to the insurance company whose name is checked above. The Company shown above is solely responsible for the obligation and payment of benefits under any policy that it may issue. No other Company is responsible for such obligations or payments.Mailing Instructions: Send form(s) to:...»

«Cantando A La Libertad Spanish Edition Ahead into payments built a condo or key goods you Cantando A La Libertad (Spanish Edition) said with the type, an forums not had this % safer without who they was. A in the record needs construction of the samples have that companies, and buy reasonably Cantando A La Libertad (Spanish Edition) when to keep the best time that you educated your slow account or corporate borrowers. These 2005 also is the least products risk not. The state should need one...»





 
<<  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.