pennsylvania application for subsidized child care · 2017-08-08 · if you want help in paying...

If you want help in paying your child are costs, you must complete this application. This is an application for subsidized child care. This application is also available in Spanish. If you need help with reading and/or completing this application, please contact your local CCIS agency.

Si necesita ayuda para pagar los gastos de guardería de su hijo, complete este formulario. Es una solicitud para recibir cuidado infantil subvencionado. Si necesita ayuda para leer o completar esta solicitud, comuníquese con la oficina de CCIS de su localidad.

Nếu quí vị muốn đượ trợ cấp để trả chi phí trông nom sӑn sóc con em quí vị, quí vị cần điền chi tiết vào mẫu đơn này. Ɖây là mẫu đơn xin hưởng trợ cấp trông nom sӑn sóc trẻ em. Nếu quí vị cần trợ giúp để đọc/hay điền đơn này, xin liên hệ cơ quan CCIS nơi qui vị cư ngụ.

Eсли вам требуетя помощь в оплате детского сада для вашего ребенка, вы должны заполнить данную форму. Эта форма - заявление на субсидированное обслуживание вашего ребенка в детском саду. Eсли вам нужна помощь в чтении и/или заполнении данной формы, обращайтсь в бюро CCIS по месту жительства.

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如果您需要钱用于托儿服务，您必须填写此申请。这是一个育儿补充应用程序。此应用程序也提供西班牙语。如果您需要帮助阅读或完成本申请，请联系您当地的CCIS组织。

Pennsylvania Application for

Subsidized Child Care

CY 868 4/17

Parent/Caretaker Name: CCIS Record #:

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Subsidized Child CareThe subsidized child care program helps low-income families pay their child care cost. You must live in Pennsylvania; apply in the county where you live and have a child or children who need child care while you are working or attending an education or training program.

By completing this application, the Child Care Information Services (CCIS) agency will be able to determine if you and your family are eligible to receive subsidized funding to help pay for your child care services.

You may submit your completed application by mail, fax or hand-deliver to the local CCIS agency. If you wish, you may complete a subsidized child care application on-line at www.compass.state.pa.us.

Note: After you submit your completed application, you will be asked to show documents to verify your information. The CCIS agency will let you know the exact information/documents you need and the time period you will have to submit all required information.

Here are some of the basic requirements:

Residency Do I have to live in Pennsylvania? YES

Employment/Training or Education Program

Do I have to work or train a certain number of hours per week?

YES - At least 20 hours per week, which can include 10 hours of work and 10 hours of training.

I am a teen parent; do I have to be enrolled in school?

If you are a teen parent, you must be enrolled in school full-time.

Income Are there income guidelines? Yes - See the inserted chart.

Cost Do I have to pay for child care services?YES - The co-pay is based on your income and family size.

Income Guidelines: The Income Guidelines change every year based on the Federal Poverty Income Guidelines (FPIG). The inserted chart will show you the maximum amount of income by family size for subsidized child care. Some family expenses may be deductible.

If you are not sure you meet the income guidelines, please complete the application and we will let you know if you qualify.

How to complete this application: Please follow the instructions in each section and remember to sign and date the application affidavit on page 7 before you submit your application. If you need help completing this application, please contact the CCIS agency.


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Tell us about you: Enter your first and last name, home address, telephone numbers and email address. Please check the box if you are experiencing homelessness, live in temporary housing, or in a shelter. If so, you can give us a location where we can send your information or you can pick it up from the CCIS agency.

Proof of address can be a lease, utility bill, a deed, a rental agreement, state photo ID, driver's license, voter's registration card, or mail that you have received showing your address.

Benefits Please check yes or no to answer the question if you receive benefits or have received benefits within the last six months such as TANF cash benefits, Supplemental Nutrition Assistance Program (SNAP) benefits, or housing assistance.

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What is your first name? What is your last name? Middle initial:

What is your address? Apt. number:

City: State: ZIP code: On what date did you become a resident of PA?

If you are experiencing homelessness, live in a shelter, transitional housing, or share housing because you cannot afford your own housing, check this box.

How can we get information to you if you do not have a permanent address?

What is the primary language spoken in your home?What is your telephone number?

Cell:

Home:

Work:

What is the primary language you read in your home?

What language would you like to receive information in?

What is your military status?

Non-veteran Veteran Active National Guard/Reserves

Where should we call you if we have any questions?

Cell Home Work

What is your email address? What is the best time to call you?

Benefits:

Yes No Do you currently receive TANF cash assistance?

Yes No Have you received TANF cash within the last six months?

If yes, where? PA Other state:

Yes No Do you currently receive SNAP?

Yes No Do you receive Medical Assistance?

Yes No Do you receive CHIP?

Yes No Do you currently receive housing assistance?

Yes No Do you receive WIC?


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2

FIRST NAME, LAST NAME, MIDDLE INITIALDATE OF BIRTH

(MM/DD/YY)SEX

(M/F)OPTIONAL SSN

HOW IS THIS PERSON RELATED

TO YOU?

IS THIS PERSON RELATED TO THE SECOND ADULT?

ETHNICITY(CHECK ONLY ONE)

You Hispanic Non Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Spouse/Parent of child needing care Hispanic Non Hispanic


Child Hispanic Non Hispanic










List name of child needing service:Is the child a U.S. Citizen or in the

U.S lawfully?

Check the days that your child needs child care services.The CCIS will discuss your child care schedule to make sure you receive the services you need.

1. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday





Tell us about your children who need child care services. List the name of your child or children living in your home who need child care or early learning services. (Turn to page 10 to add more children.)

Check the box Yes or No to answer if your child is a U.S. Citizen or in the United States lawfully and admitted for permanent residence. Check all days that you need child care services. The CCIS agency will discuss your child care schedule with you at your face-to-face meeting.

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List all members of your household and their relationship to you. Enter the first and last name including the middle initial of all members of your household for whom you are responsible. Enter their date of birth, their sex M (male) or F (female). If you list your Social Security number (SSN), it will only be used to identify your case. What is the

household member’s relationship to you? Is this family member related to the second adult? Check the race and ethnicity of each family member; you may select all that apply. (Turn to page 10 to add more names.)

Proof of family composition can include a birth certificate, a custody order, a medical record or a written statement from a physician, or a school record. If you are a foster parent, you must submit a letter from the county Department of Human Service (DHS) or Children Youth and Families (CYF) that approves the foster child to be in care.


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Immunization Certificate:

I certify that my child(ren) listed below has/have received their age appropriate immunizations (shots):

I certify that my child(ren) listed below does/do NOT have age appropriate immunizations (shots) because of: Religious beliefs; or A medical condition of the child.

Parent Signature: Date:

Additional Information About Your Child: Please check all boxes that may tell us about your child: If your child is learning English as a second language, transfers to different schools because the parent or guardian is a migrant worker, if there is an absent parent who may be incarcerated or deceased, or if the child was referred by a health/mental health service.

Yes No Are any of the above children learning English as a second language?

If yes, what is the child's name?

Yes No Have any of the above children attended a Head Start or Early Head Start program?


Yes No Have any of the above children been referred to PA Pre-K Counts from another health or mental health agency?


Yes No Have any of the above children moved from one school district to another because their parent or guardian is a migrant worker?


Yes No If any of the above children have an absent parent, is the parent: Deceased In the military Incarcerated (prison)

Not living in the same household Whereabouts unknown


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EMPLOYMENT Is this person employed?Is this person self-

employed?Place of employment or self-employment:

Does this person need child care while working?

Yourself Yes No Yes No Yes No

Spouse/Live-In Parent of Child

Yes No Yes No Yes No

TRAINING Is this person in a training program?

Place of training:Does this person need child care while attending

the training program?

Yourself Yes No Yes No

Spouse/Live-In Parent of Child

Yes No Yes No

EDUCATION - If you are a teen parent:

Yes No Are you enrolled in elementary, middle school, high school, or a GED program?

Yes No Do you need child care while you are attending your education program?

Employment/Education/Training: Check Yes or No if you are employed or enrolled in an education ortraining program. Please check Yes or No if you need child care while you are working or while you are attending the education or training program. You must submit proof of the days and hours you are working or enrolled in an education or training program.

Proof of employment/education or training must include a letter or a form (see enclosed) that shows the name of your employer, school or training program. It should state your actual days and daily schedule (such as Monday - Friday 9 AM - 5 PM) and your total number of hours weekly. If you are employed, the form should also include how often you are paid: weekly, bi-weekly (26 pays), twice a month (24 pays), monthly or annually. The letter or form must be signed and dated by your employer or authorized school representative.


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Voter Registration Preference Question (Optional) If you are not registered to vote where you live now, would you like to apply to register to vote here today?

Yes No OR I am already registered to vote where I live now.

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

To register, you must:1. Be at least 18 on the day of the next election.2. Be a citizen of the United States for at least one month PRIOR TO THE NEXT ELECTION;3. Reside in Pennsylvania and the voting district at least 30 days prior to the next election.

Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this agency.If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Please contact the CCIS agency if you would like help. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Secretary of the Commonwealth, PA Department of State, Harrisburg, PA 17120. (Toll-free telephone number 1-877-VOTESPA.)

Yes No Does anyone in your home receive income? If Yes, check all that apply:

Wages SSI Rent Unemployment compensation Child support

Social Security Room and Board Workers Compensation Spousal support Commission

Alimony Union pay Interest Other:

NAME OF PERSON WHO RECEIVES INCOME: TYPE OF INCOME:HOW OFTEN DO YOU

RECEIVE INCOME?HOW MUCH INCOME DO

YOU RECEIVE?DATE LAST RECEIVED:

Yes NoDo you or your spouse/live-in parent of the child needing care; have medical expenses that were not paid by insurance within the past 90 days, which will continue for the next six months? Proof of medical expenses may include doctor bills, hospital bills, dental bills, health care premiums, bills for medication, prosthetic devices, and/or bills for durable medical equipment.

Yes No Do you or your spouse/live-in parent of the child needing care, pay child support or alimony to someone who does not live with you? If YES, attach proof of child support or alimony you are ordered to pay.

Yes No ASSETS: Do you have assets over one-million dollars?

Income and Expenses: Answer the question Yes or No if you or someone in your home receives income (do not listthe earned income of minor children). Check all the boxes of income types that are received. If income you receive is not listed, write the source in Other. List the name, type of income, amount, and how often the income is received.

Proof of income may include pay stubs showing your gross earnings, an employer statement showing gross earnings and how often you are paid, a letter from the government agency for SSI or Social Security Benefits, unemployment compensation letter, child support or alimony letter showing the amount and how often it is paid and if you are self-employed, you may submit your tax returns for the previous year and all supporting documentation.

Proof of expenses paid out may include medical bills for the last three month period, a court-order for child support payments paid for a child not living with you or alimony payments.


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Permission to Share: Your information will be reviewed and a determination of subsidized eligibility will be made.However, if you are not eligible for subsidized child care, you may be eligible for another Pennsylvania early learning program such as Pre-K Counts, Head Start or Early Head Start.

We are asking your permission to share your application with another Pennsylvania early learning program such as Pre-K Counts, Head Start or Early Head Start if you are not eligible for subsidized child care.

By signing below, you are giving us permission to share your application and all documents you submitted with another early learning program that may meet the child care needs of you and your family.

We will discuss this with you before sharing your information.

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Release of Information: By my signature below, I am giving the CCIS agency permission to contact reliablesources to verify information. This release is also permitting the CCIS agency to contact people on my behalf when they are unable to reach me.

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Yes I give permission to the reviewer of this application to share my application and all documents I have submitted with one or more of the early learning programs to determine if I am eligible for their services.

I understand that my information will be reviewed again and that the program will contact me in writing or by telephone to inform me of my status or if I need to submit additional information.

No I do not give permission to the reviewer of this application to share my application with other early learning programs.

Parent/Caretaker Signature: Date:


I hereby authorize and request the disclosure to the Child Care Information Services (CCIS) agency to contact reliable sources for knowledge of information pertinent to verification of: identity; residence; employment; education and training activities; family size and composition; care and control of child(ren) residing with a grandparent, aunt or uncle; reasons for subsidy suspension; income; and any additional information pertinent to eligibility for the Subsidized Child Care Program for myself and/or those individuals on whose behalf subsidy benefits are paid. I understand that the information obtained will be used only for purposes directly related to the determination or eligibility for the Subsidized Child Care Program.



CCIS Representative Signature: Date:

In the event I cannot be reached, I give the CCIS agency permission to contact the person(s) identified below:

NAME TELEPHONE NUMBER RELATIONSHIP TO YOU

The above names shall remain active until I contact the CCIS agency to remove them from my list of alternate contact names.


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Affidavit: An affidavit is a sworn statement of fact. By signing this affidavit, you are saying that the information you enteredin this form is true. The affidavit is the legal way to swear that your statements are fact. The parent or person applying for the early learning program should sign and date this application. Your signature validates the information you entered into the form.

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I affirm that I have read or have had this application read to me in full and that I have received a written copy of my Rights and Responsibilities form on page 8. All information I have given is true, correct and complete to the best of my ability, knowledge and belief. I understand that the information in this application will be used to determine my eligibility for subsidized child care and may be used for Pre-K Counts, Head Start or Early Head Start, if my permission is given. I understand that information contained in this application may be shared with other Department of Human Services programs and the Office of the Inspector General. Further, I understand that I can be penalized by fine or imprisonment or subsidized child care ineligibility for making false statements or for my failure to report a change that I am required to report. I understand that changes are listed on the subsidized child care Rights and Responsibilities form on page 8. I understand that if I receive child care for which I was not eligible, I will be required to pay back the cost of the subsidized child care I received during the period of time when I was ineligible.



Date and Time StampApplication received in CCIS office:

CCIS USE ONLY

PELICAN Record #

Meets subsidy requirements effective: Applicant notified in writing.

Does not meet subsidy requirements effective: Applicant notified in writing.

Reason for ineligibility:

CCIS Representative Signature: Date:


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Rights and Responsibilities: You have the right to be treated fairly and with respect.

Your rights and responsibilities will be reviewed and discussed with you in detail by a person from the CCIS agency.9

I understand that:

• The information in this form will be kept confidential.

• I may pick any eligible child care provider for my children. An eligible provider meets the requirements of the Subsidized Child Care Program and agrees to follow the Department of Human Services rules.

• I may need to pick another provider if my provider is not eligible to participate in the Subsidized Child Care Program.

• I will be told in writing when a change causes my family to lose help in paying for child care and that I may ask for hearing if I disagree with a decision that the CCIS agency has made.

• I must give the CCIS agency true and complete information and proof of information as requested.

• I must contact the CCIS agency within ten days following the date:- A parent or caretaker in my family permanently loses work;- My family’s gross monthly income exceeds income limits based on the flyer the CCIS provided me for reference;- I begin or return to work following maternity, paternity or adoption leave;- I begin or return to work following disability leave; or- The child no longer has a need for care or is no longer residing in the household.

• It is important that I contact the CCIS agency immediately if there is a change to:- My address;- My telephone number;- Who is providing child care for my child(ren); or- The number of days and hours my child needs care.

After the CCIS has determined you eligible for child care and funds are available to enroll your child(ren) in care, you need to know the following:

1. You must pay a co-payment to your provider every week. The co-payment is due to the provider on the first day of the week that your child(ren) attend(s). It is important that you pay your co-payment on time. If you do not pay your co-payment on time, you may lose the CCIS agency’s help in paying for your child care.

2. Unless your child is ill, your child must attend the child care program on all the days that you told the CCIS agency he/she needed child care. If you need to make a change due to your work, education or training schedule, you must call the CCIS agency. You could lose the CCIS agency’s help in paying for your child care costs if your child is absent for five days in a row for a reason other than: (1) Illness, injury or hospitalization of the child or another family member; (2) Family/maternity leave; (3) Visitation with a parent who does not live with the child(ren) or (4) A break in your work, education or training.

3. If your child is absent for more than 25 enrollment days between July 1 and June 30, you will be responsible to pay the provider the daily rate for each day of absence beginning with the 26th absence. You must pay the provider’s daily rate in addition to your weekly co-payment. For example, if your co-payment is $20/week and the daily rate is $20, you must pay $40 for the week that includes your child’s 26th day of absence.

4. The CCIS agency will pay a child care center, family child care home or a group child care home for up to 15 days when the facility is not open to care for your child. The CCIS agency is unable to pay an alternate child care provider during these 15 days when your provider is not open to care for your child.

5. If the CCIS agency sends you a Notice of Adverse Action, it means there may be a change in your eligibility for subsidized child care. If you do not understand what is written in the notice, you should contact the CCIS agency immediately. If you disagree with a decision that the CCIS agency has made, you may ask for a hearing to review the decision. You must inform the CCIS agency that you do not agree with the decision by doing one of the following: (1) Fill out the bottom part of your notice or write a letter and then mail, fax or take the information to the CCIS agency; and (2) Call the CCIS agency to discuss the reason you do not agree with the decision and follow-up by putting your concerns in writing within seven days following the date of your telephone call with the CCIS agency. If you want the CCIS agency to continue to help pay for your child care during this process, you must mail, fax or take the bottom part of your notice or the letter that you wrote to the CCIS agency or call the CCIS agency on or before the date on the Notice of Adverse Action.

6. You may choose a new provider at any time. However, you must tell the CCIS agency and the CCIS agency must issue a new authorization before your child can begin child care with the new provider. The CCIS agency will authorize the transfer and continue to help pay for your child care after the transfer if: your family co-payments are up-to-date AND you continue to be eligible for the CCIS agency’s help in paying for your child care AND the new provider that you choose meets the requirements of the Subsidized Child Care Program. The new provider must also agree to follow the Department of Human Services rules. If the CCIS agency does not authorize the transfer, you will be responsible for paying the total cost of child care at the new provider.

Date discussed with parent/caretaker: Initials of worker:

My signature below confirms that my Rights and Responsibilities were explained to me and that I have received a copy for my records:



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Access to Other Services and Information: By answering these questions, we will be able to send you information about other services you may need.

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Yes No 1. Do you need help finding a quality child care program to meet the needs of your child and family? The CCIS agency can help you locate a quality child care program.

Yes No 2. Would you like information about Pre-K Counts? If you have a child between the ages of 3 and 4, you may be eligible for Pre-K Counts. You do not have to be employed to receive Pre-K Counts.

Yes No 3. Would you like information about Early Head Start or Head Start? If you are pregnant, have a child from birth up to 3 years old,

you may be eligible for Early Head Start. If you have a child from 3 to 5 years old, you may be eligible for Head Start. You do not have to be employed to receive Head Start or Early Head Start.

Yes No 4. Does your child(ren) need health insurance? Pennsylvania's Children's Health Insurance Program (CHIP) provides health insurance to children and teens who are not eligible for or enrolled in Medical Assistance.

Yes No 5. Would you like information on Pennsylvania's supplemental food program for Women, Infants, and Children (WIC)? If you are

pregnant, breastfeeding, not breastfeeding, or have an infant or children under age five, including foster children, you may meet the requirements to receive nutritional support from the WIC program.

Yes No 6. Do you need dental or vision care?

Yes No 7. Do you need health insurance?

Yes No 8. Would you like information about Pennsylvania's Home Visiting Programs? Home Visiting Programs provide resources and skills

to help raise children who are physically, socially, and emotionally healthy and ready to learn. If you are: pregnant, an expectant father, a parent, a caregiver of children, or a member of a family that may be considered at-risk, you may be eligible.

Yes No 9. Would you like information about a child's developmental stages?

Yes No 10. Are you concerned about your child's development?

Yes No 11. Would you like information about high quality child care and Keystone STARS?

Yes No 12. Do you need help paying for food? (SNAP)

Yes No 13. Would you like information about free and reduced school meals?

Yes No 14. Do you need help paying for your heating, electric, or gas? The Low Income Home Energy Assistance Program (LIHEAP) helps low income families pay their heating bills. The payments would go directly to the utility company if you qualify.

Yes No 15. Do you need information about housing or rental assistance?

Yes No 16. Would you like to take classes to learn English as a second language (ESL)?

Yes No 17. Would you like to enroll in a program to get your high school equivalency diploma (GED)?

Yes No 18. Would you like to enroll in a job training program?

Yes No 19. Would you like information about the Earned Income Tax Credit (EITC)? You may be eligible for an EITC if you work and earn low to modest incomes. If you are eligible, you may pay less federal taxes, no taxes, or get a refund.


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FIRST NAME, LAST NAME, MIDDLE INITIALDATE OF BIRTH

(MM/DD/YY)SEX

(M/F)OPTIONAL SSN

HOW IS THIS PERSON RELATED

TO YOU?

IS THIS PERSON RELATED TO THE SECOND ADULT?

ETHNICITY(CHECK ONLY ONE)











List name of child needing service:Is the child a U.S. Citizen or in the

U.S lawfully?

Check the days that your child needs child care services.The CCIS will discuss your child care schedule to make sure you receive the services you need.






Continued from #2 on Page 3: Use this page to list additional children living with you.

Continued from #3 on Page 3:

Remember: You can mail, hand-deliver, or fax this application to the CCIS agency.

Did you answer all questions??

Did you sign and date the Affidavit on Page 7??

CY 868 4/17

Employment Verification Form

EMPLOYER NAME/PLACE OF EMPLOYMENT: IMMEDIATE SUPERVISOR’S NAME: IMMEDIATE SUPERVISOR’S TITLE:

I authorize the release of this information and give permission to the Child Care Information Services (CCIS) agency to verify all information contained in this form.

EMPLOYEE’S PRINTED NAME EMPLOYEE’S SIGNATURE DATE

THE FOLLOWING SECTIONS MUST BE COMPLETED BY THEIR EMPLOYER EMPLOYER IDENTIFICATION NUMBER (EIN): ADDRESS OF EMPLOYMENT: EMPLOYER’S TELEPHONE NUMBER:

(______) ______ - ____________

EMPLOYEE INFORMATION EMPLOYEE’S JOB TITLE:

Is the above-mentioned employee newly hired? Yes No EMPLOYMENT START DATE:

______ / ______ / ____________

EMPLOYMENT INCOME HOURLY RATE:

$

GROSS PAY:

$

AVERAGE DAILY TIPS:

$

NEXT PAY DATE:

___ / ___ / ______

PAY FREQUENCY:

Weekly Bi-Weekly (26 pays/year) Twice a Month (24 pays/year) Monthly

The employee: receives paystubs does NOT receive paystubs has access to pay online via the following website:

EMPLOYMENT SCHEDULE (Please indicate the days and hours the employee works and indicate whether the hours occur during A.M. or P.M.)NOTE: If the schedule varies, please give a 4-week sample schedule.

WEEK ONE Dates: from: _________________

to: ___________________

Mon. from ________ a.m./p.m. to ________ a.m./p.m. Tues. from ________ a.m./p.m. to ________ a.m./p.m. Wed. from ________ a.m./p.m. to ________ a.m./p.m. Thur. from ________ a.m./p.m. to ________ a.m./p.m. Fri. from ________ a.m./p.m. to ________ a.m./p.m. Sat. from ________ a.m./p.m. to ________ a.m./p.m. Sun. from ________ a.m./p.m. to ________ a.m./p.m.

TOTAL # HOURS/WEEK: _________________________

WEEK TWO Dates: from: _________________

to: ___________________


TOTAL # HOURS/WEEK: _________________________

WEEK THREE Dates: from: _________________

to: ___________________


TOTAL # HOURS/WEEK: _________________________

WEEK FOUR Dates: from: _________________

to: ___________________


TOTAL # HOURS/WEEK: _________________________

Effective begin date of schedule change:

EXTENDED LEAVE

Is the employee on extended leave (maternity, disability, etc.)? Yes No Effective begin date of extended leave: ___ / ___ / ______ Date returned from extended leave: ___ / ___ / ______

TEMPORARY/SEASONAL EMPLOYMENT

Is the employee considered to be a temporary hire? Yes No If the employee is considered a temporary hire, what is the last date of guaranteed employment? ___ / ___ / ______

If the employee is seasonal, please give: Last day of work before break: ___ / ___ / ______ Expected date of return following break: ___ / ___ / ______ I understand that the information I am providing will be used to determine the above-named employee’s eligibility for subsidized child care.

EMPLOYER’S PRINTED NAME & JOB TITLE EMPLOYER’S SIGNATURE DATE CY 925 12/15

Employment Verification Form

Dear Employer:

One of your employees has requested assistance paying his/her child care costs. We must verify his/her employment with you. This information will help us determine if this employee is eligible for the subsidized child care program. The form must be mailed directly to the Child Care Information Services (CCIS) agency.

An authorized COMPANY REPRESENTATIVE (not the employee) must complete this form.

We must have an accurate record of your employee’s work schedule and employment income. Please complete the information on the back of this page. It is very important that the hours shown are specific and defined as either A.M. or P.M. (For example, 7:30 a.m. - 3:30 p.m.). If the employee’s schedule varies, please give a 4-week sample schedule. You do not need to give a 4-week sample schedule unless the employee’s schedule varies from week to week.

Thank you for your time and assistance. If you have any questions about how to complete this form, please contact the CCIS listed below.

CCIS:

CY 925 12/15

Online Services for the Child Care

Works Program

Submit an application or redetermination through

online services for the Child Care Works Program!

Go COMPASS today!

www.compass.state.pa.us


COMPASS is a website providing online access to social

services for Pennsylvanians.

For assistance or questions about COMPASS, please call

1-800-692-7462

This program is made possible by the

Pennsylvania Department of Human Services

PUB 562 12/15

www.dhs.pa.gov

CHILD CARE INFORMATION SERVICES OF BERKS COUNTYA program of the Berks County

Intermediate Unit610-987-CCIS (2247)

800-257-30381111 Commons Blvd•PO Box 16050

Reading, PA 19612-6050FAX: 610-987-8428

www.berksiu.org/ccis

Relax!It’s easy ...

COMPASS does it all!

• Submit an application orredetermination for the Child CareWorks Program through COMPASS

• View the status of your Child CareWorks application

Help is only one click away!

Complete the online applica-tion or redetermination and it will automatically be sent to your local Child Care Information Services, CCIS, office.

This can be done from any computer with Internet access. The site is secure and your information is completely confidential.

To learn more, visit:


TODAY!

Looking for a child care provider in your area?

Search online through COMPASS at:www.compass.state.pa.us/childcaresearch

• Easy and convenient• Detailed information on child

care providers• Search based on your

preferences

“It’s about time ...”Start the application process when it is convenient for you!

• COMPASS is open 7 days a week, 24hours a day!

“Peace of mind ...”Find out if you might qualify for Child Care Works financial assis-tance!

• Complete a screening or apply to findout if you may qualify!

“Ongoing convenience ...”Submit your redetermination from your home!

• Renew through COMPASS!

A Parent’s Handbook to Subsidized Child Care

Pennsylvania Department of Human ServicesOffice of Child Development and Early Learning

In partnership with Child Care Information Services

A PARTNERSHIP OF CARING

MEETING THE NEEDS OF CHILDREN AND FAMILIES IN A CARING WAY

A Letter to Parent/Caretakers .............................................................................Page 4Questions & Answers about Subsidized Child Care

Helpful Hints ......................................................................................................... Page 14Who can I call with more questions? ............................................................... Page 15

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T A B L E O F C O N T E N T S

I need help finding and paying for child care. Pages 5-8

Now that I meet the guidelines - What do I need to know? Pages 9-12

What are my rights and responsibilities in the subsidized child care program? Pages 13-14

1. What is subsidized child care? .................................................................................. 52. What is the Child Care Information Services (CCIS)? .........................................53. What are the guidelines for the subsidized child care program? ................... 5-64. How do I show that I meet the guidelines? ............................................................65. What if I have a special case? ................................................................................... 76. When will my subsidized child care begin? ............................................................ 77. When my TANF cash assistance ends can I get subsidized child care? ...........8

1. Will I have to help pay for my child care? ...............................................................92. How can I get help finding child care? ....................................................................93. What types of child care programs are there? .................................................9-104. What if my information changes? .......................................................................... 115. What if I lose my job or become disabled? .......................................................... 116. What if I move to a new county? ............................................................................ 127. How often will the CCIS review my case? ............................................................. 12

Dear Parent/Caretaker:

We welcome you to Pennsylvania’s subsidized child care program, a partnership between parents, providers, the Child Care Information Services, CCIS, and the Office of Child Development and Early Learning.

The children of Pennsylvania are the keys to tomorrow. We prepare our children during the early years so that they are ready for each stage of learning.

Each county in Pennsylvania has a CCIS Office. The staff members are trained to help you as you make your child care decisions. Your county’s CCIS office is listed on the back of this handbook.

We hope that this Parent Handbook will answer your questions about subsidized child care. We look forward to working with you and your family.

Office of Child Development and Early Learning

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OFFICE OF CHILD DEVELOPMENTAND EARLY LEARNING

Office of Child Development & Early Learning 333 Market St., 6th Floor

Harrisburg, Pennsylvania 17126

1. What is subsidized child care?

The subsidized child care program helps low-income families pay their child care fees. The state and federal governments fund this program, which is managed by the Child Care Information Services, CCIS, located in your county.

If you meet the guidelines:• The CCIS will pay a part of your child care fee. This is called a subsidy payment.• You will pay a part of the fee. This is called the family co-pay.• The subsidy payment and the family co-pay go directly to the child care program.

Note: If your child care subsidy does not pay the full amount that your child care program charges, the provider may ask you to pay the difference between the subsidy payment and their private charges.

2. What is the Child Care Information Services, CCIS?

The Child Care Information Services, CCIS, office is the center for child care information and child care help in your county. You can call or visit the CCIS office for a subsidized child care application. You can also apply for subsidized child care on-line at www.compass.state.pa.us.

The CCIS will:• Review your application to see if you meet the guidelines for the subsidized child care program.• Help you find a child care program.• Provide information and ideas about how to select the best possible early learning program or setting

for your child.

If you receive TANF cash assistance benefits and attend an approved employment/training activity, ask your county assistance caseworker to refer you to the CCIS for child care assistance.

3. What are the guidelines for the subsidized child care program?

You must submit an application to the CCIS office to see if you meet the guidelines for the subsidized child care program.

The following are the basic guidelines:• You must live in Pennsylvania• Have a child or children who need child care while you work or attend an education program• Meet income guidelines for your family size• Work 20 or more hours a week -or-• Work 10 hours and train 10 hours a week• Have a promise of a job that will start within 30 days of your application for subsidized child care• Teen parents must attend an education program

5

I need help finding and paying for child care.

6

• The child who needs care must be a citizen of the United States or an alien lawfully admittedfor permanent residency.

• Have proof of identification for each parent or caretaker in the home.• Have proof that each person on your application is a member of your family.

4. How do I show that I meet the guidelines?

You must submit a subsidized child care application to the CCIS.

You may call the CCIS in your county to request an application. The CCIS will mail the application to you. You can also visit the CCIS to pick up an application or apply online at www.compass.state.pa.us.

Make sure that you read the directions on the application carefully. If you have any questions, call the CCIS. Complete all sections of the application and make sure that you sign and date the application before you return it to the CCIS. You may file your application in person, by mail, by fax or apply online.

Note: Please note that certain items that are needed to see if you meet the subsidized child care guidelines are based on your word and some require outside proof.

If you are having problems getting the needed information, let the CCIS know right away. The CCIS will help you get the information you are unable to obtain.

The CCIS will ask you to sign a consent form so that they can help you get the needed information.

The information you provide will be kept confidential. The information in your file will be used for your participation in the subsidized child care program.

• You may self-certify information - this means the CCIS will accept a statement from the parent orcaretaker as proof of the following information:

(1) Age of Child(2) Citizenship or immigration status(3) Immunization status (shot records)(4) Days and hours that a child needs care (former TANF client)(5) Former TANF status(6) Extended time frame for a face-to-face meeting based on a hardship

• You may self declare information - this means you do not have to submit information right away.You can tell the CCIS the information that is needed. You will then have 30 days to submit the proof.You will need to sign a form given to you by the CCIS.

The CCIS will send you a notice to let you know if you meet the guidelines. This notice is called a Child Care Eligible Notice. If you do not meet the guidelines, the CCIS will send you a notice called a Child Care Ineligible Notice.

5. What if I have a special case - can I get subsidized child care?

Maybe. The CCIS will let you know what you will need to submit for each special case.

The following are examples of special cases:• Disabled Child - If you have a child between the ages of 13 and 19 who is physically or emotionally-

disabled and unable to care for himself, that child may be eligible for the subsidized child careprogram.

• Disabled Spouse - If you have a disabled spouse who cannot care for your children while you work,your family may still meet the guidelines for the subsidized child care program. Your spouse willneed to submit proof from their doctor or licensed psychologist.

• Domestic Violence - If you are a victim of domestic violence, you can request a waiver from the CCIS.A waiver means some of the guidelines will be delayed for a period of time. You will need to completea form. The CCIS will never contact the person who is causing the domestic violence.

• Shared Custody - If you share custody of your child and you need child care while you work, you maymeet the guidelines for the subsidized child care program. If you meet the guidelines, you will receivesubsidy on the days that you have your child.

• Foster Parent - If you have a foster child and you need child care while you work, submit a subsidizedchild care application to the CCIS along with a letter from the county’s Children and Youth Agencyexplaining that you are a foster parent and that the foster child needs child care.

• Head Start Child - If you have a child who is enrolled in a Head Start program and you need childcare to continue working, submit proof of enrollment from the Head Start program.

• Pre-Kindergarten Child - If you have a child attending Pennsylvania Pre-K Counts or apre-kindergarten program that is certified by the area school district and you need additional childcare hours beyond the Pre-kindergarten program to continue working, you will need to submit proofof enrollment from the school.

Please talk to your CCIS if you think you have a special case that is not listed.

6. When will my subsidized child care begin?

Once you meet the guidelines for the subsidized child care program, this is what will happen:

The CCIS will send you a Child Care Eligible Notice.

a) If funds are available, you will need to do the following within 30 days:I. Meet with the CCIS worker for a face-to-face interview

II. Select a child care program that meets the Provider Standards of the Office of Child Developmentand Early Learning

III. Enroll your child in a child care program

b) If funds are not availableI. Your name will be placed on a waiting list

II. The CCIS will send you a letter when subsidized funds are availableIII. When you receive the letter you will have 30 days to:

A. Meet with the CCIS worker for a face-to-face interviewB. Select a child care program which meets the Provider Standards of the Office of Child

Development and Early LearningC. Enroll your child in a child care program

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If funds are available, subsidized child care payments may begin from the date that yourapplication was received in the CCIS Office. The CCIS will let you know the start date ofsubsidized child care payments on the enrollment summary.

7. When my TANF cash ends, can I get subsidized child care?

If you receive TANF cash assistance benefits within the last six months and you have a child who needs care while you are working, you may meet the guidelines for continued subsidized child care.

The CCIS will send a letter to TANF families when their cash benefits end. The letter will let you know what you need to do to continue receiving subsidized child care or to begin receiving subsidized child care.

If you were getting child care assistance while you received TANF and are working, your case will be transferred to the CCIS office when your TANF benefits end. This means your child care funding will continue from the date your cash closed.

If your TANF cash assistance benefits were closed and you did not receive a letter from the CCIS and you need child care, contact the CCIS office right away.

8

“A partnership of caring - leads to

successful outcomes.”

9

1. Will I have to help pay for my child care?

Yes. All families in the subsidized child care program pay a family co-pay amount. The co-pay is based on your family size and income. Your family co-pay will start on the first day that subsidized child care payments begin.

Important family co-pay information:

• Your family co-pay will not increase for a six month period.

• If your income decreases, you can notify the CCIS. Your co-pay may be lowered based on the newinformation.

• Your first family co-pay must include one week and a deposit equal to the first co-pay amount.

• The family co-pay is due on the first day of each week.

2. How can I get help finding child care?

Call the CCIS office. A parent services staff will talk to you about child care options. You will get a list of child care programs that you can call or schedule an appointment to visit. You can also do your own pro-vider search through the online childcare provider search located on the COMPASS website.

3. What types of child care programs are there?

There are over 9,000 certified child care programs in Pennsylvania. These include center, group and fam-ily day care homes. The Office of Child Development and Early Learning inspects all certified centers and group day care homes once a year. Unannounced visits are also made to those certified programs. A sam-ple of registered family day care homes are selected each year for an on-site inspection.

Each teacher, assistant teacher and aide in a certified or registered child care program must:

• meet educational guidelines

• participate in on-going professional development

• pass Federal and State clearances which include fingerprinting, criminal history and child abuseclearances,

• have a health assessment

Now that I meet the guidelines - What do I need to know?

“We prepare our children so that they

are ready for each stage of learning.”

Child care centers and group day care homes must have a Certificate of Compliance to operate in Pennsylvania.

The Certificate of Compliance must be posted at the location. It will show the name and address of the program, the number of children they are allowed to care for and the expiration date of the certificate.

Family Day Care Homes must have a Certificate of Registration to operate in Pennsylvania.

The Certificate of Registration must be posted in the home. It will show the name of the provider and the expiration date of the registration. A Family Day Care program can only care for up to six children at one time who are unrelated to the provider.

The following provider types are uncertified and unregistered. To receive subsidized child care payments, these providers must pass Federal and State clearances which include fingerprinting, criminal history and child abuse clearances.

The uncertified unregistered providers include:

• Relative/Neighbor Provider (R/N)A R/N provider can only care for up to three children at any one time.

• In-home ProviderThis provider cares for your child in your home. You are considered the employer. You must pay thisprovider at least the minimum wage and pay all required federal and state taxes as an employer.

Subsidized child care payments can only be made to an in-home provider under the following special conditions:

• If you work between the hours of 9:00 p.m. and 6:00 a.m. or

• If care outside the home is a risk to the child’s health. (The child’s health condition must bedocumented by a licensed physician or psychologist. The letter must also explain why the child needsin-home care.)

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Pennsylvania offers a special program called Keystone Stars to certified and registered pro-viders. Keystone Stars is a quality improve-ment program that helps child care providers develop and train staff to support a child’s development, early learning and school readi-ness.

Providers who have a Keystone STARS rating have met additional quality standards established by the Department of Human Services.

11

4. What if my information changes?

Call your CCIS office. Some changes must be reported within 10 days of the change, other changes are helpful to report just in case the CCIS needs to contact you.

The CCIS will work with you whenever there are changes in your information.

5. What if I lose my job or become disabled?

If you lose your job, call the CCIS office right away. The CCIS will explain to you what you will need to do. If you were laid-off or fired from your job while receiving subsidized child care, funding will continue for up to 30 days, and your eligibility will continue for up to 60 days, giving you time to find a new job. If you quit your job you will be given 13 days of continued subsidized child care funding.

If you become disabled while receiving subsidized child care and are unable to continue working, call the CCIS office. If you are unable to care for your child during your disability, subsidized child care funding will continue up to six months from the date you stopped working. You must submit proof from your doctor or psychologist. If you go on Family leave or Maternity leave, subsidized child care may continue for 12 weeks from the date that your family or maternity leave started.

You must submit:• A letter from your employer or doctor which states the date family or maternity leave started.• Income information (Your family co-pay may be lowered based on the new information)

Talk to the CCIS about your child care options when you go on Family leave, Disability or Maternity Leave.

• You may continue to send your child who is receiving care to the child care program -or-• You may suspend subsidy for up to 90 days or until you return to work within the 12 week period.

Note for parent/caretakers on Maternity Leave - Let the CCIS know if you will need child care for your newborn. If funds are available, care may begin once you return to work. If funds are not available, your newborn will be placed on the waiting list from the date of your request.

CHANGES THAT MUST BE REPORTED WITHIN 10 DAYS OF THE CHANGE:

If you lose your job, including a layoff or strike Your hours of work or training drop below 20 hours per week

Start of disability and the date you return to work Start of maternity, paternity or adoption leave and the date you return to work

A change in the days and hours child care is needed A change in family size

Change of address

CHANGES THAT ARE HELPFUL TO REPORT

A decrease in pay A new job

A new home telephone number A new job telephone number

6. What if I move to a new county?

If you move to a new county, your subsidized child care funding will continue based on your new informa-tion. The CCIS will transfer your records to the CCIS office in the new county. You should let the CCIS know before you move so that subsidized child care payments will continue. The CCIS in the new county will also help you locate a new child care program.

7. How often will the CCIS review my case?

Once you complete your application and meet the guidelines for the subsidized child care program, the CCIS will review your case every six months. This process is called a redetermination of eligibility.

A redetermination means the CCIS will review your family income, work and training status and your continued need for subsidized child care. You must provide up-to-date proof of your family’s earned income at each redetermination.

You will not need to provide any other proof unless there has been:• A change in unearned income received by your family• A drop in your hours of work, education or training below an average of 20 hours per week• A new job• A change in your family size

The CCIS will mail a Redetermination Summary to your home address. It will include the date that you will need to submit your up-to-date information. You may fax, mail or bring your information to the CCIS office or complete your redetermination online at www.compass.state.pa.us.

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13

Parent/Caretaker Rights:You have the right to be treated fairly and with respect

1. You have the right not to be discriminated against. You and your family may not be discriminatedagainst in the subsidized child care program on the basis of age, race, sex, color, religious creed,national or ethnic origin, ancestry, sexual preference or physical or mental disability.

2. You have the right to examine your file. The family file contains information that is used to determineyour eligibility for the subsidized child care program. A parent/caretaker or his/her representative, ora person who was given permission by the parent/caretaker has a right to examine his or her file in theCCIS office.

3. You have the right to a timely decision. You have the right to file your signed application online at anytime or on any day that the CCIS office is open for business. The CCIS will review your application rightaway to make sure that you have all of the needed documents.

If information is missing, you will receive a Missing information letter telling you what you need tosubmit.

4. You have a right to a written notice. You have the right to receive a written notice from the CCIS office whenever a decision is made that affects your eligibility for the subsidized child care program. This includes decisions denying subsidy, terminating subsidy, setting or changing co-payments, denying a domestic violence waiver, suspending or disrupting subsidy.

There are several types of notices:

• Child Care Eligible Notice • Notice of Adverse Action• Child Care Ineligible Notice • Notice of Overpayment• Child Care Confirmation Notice • Notice Confirming Voluntary Withdrawal

5. You have the right to appeal any decision or action made by the CCIS. You have the right to appealany decision, action or failure to act by the CCIS office that affects your family’s eligibility for the sub-sidized child care program. This includes denial of subsidy, termination of subsidy, computation of theco-payment, denial of a domestic violence waiver, failure of the CCIS agency to act upon a request forsubsidy within the required time limits, or suspension or disruption of subsidy.

6. You have the right to have your subsidy continue pending a hearing whenever you get a Notice ofAdverse Action proposing to terminate your subsidized child care.

A Notice of Adverse Action is the type of notice that is used if the CCIS plans to end (terminate) orsuspend your subsidy.

The Notice of Adverse Action lists:

• The proposed date that subsidized funding will end

• The regulation that you have failed to meet

• How to file an appeal

• The deadline date to file your appeal

• The address and telephone number of the County Legal Services Office.

What are my rights and responsibilities in the subsidized child care program?

The CCIS must make a determination of eligibility within 10 days of the date that all required informationis received.

The CCIS may not delay a decision on your application beyond 30 days from the date your completedapplication was received.

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Note: If you appeal within 10 days of the date of the Notice of Adverse Action, you may continue to receive subsidized child care until your appeal is decided.

If subsidized funding continues during the appeal and the appeal is decided in favor of the CCIS, you will have to pay back the amount of the subsidy that you received during the appeal, unless the hearing officer determines that paying the amount back would create a hardship for your family.

7. You have the right to choose care from any provider who agrees to abide by the Provider Standards ofthe Office of Child Development and Early Learning.

Each provider must sign a provider agreement before the CCIS will subsidize the child care cost attheir site. The CCIS will notify the provider to let them know when subsidized child care payments willbegin.

8. You have the right to view the Rules and Regulations for subsidized child care. The rules andregulations for subsidized child care eligibility can be viewed and printed from the internet. If you donot have a computer, you can get a copy of the regulations from your CCIS office.

1. Go to www.pacode.com

2. Click on Browse (a menu will appear)

3. Select 55-Public Welfare

4. Scroll down to Chapter 3041 - Subsidized Child Care Eligibility

Title 55 - Public Welfare DEPARTMENT OF HUMAN SERVICES

[55 PA.CODE CHAPTER 3041] Subsidized Child Care Eligibility

Parent/Caretaker Responsibilities: As a parent/caretaker who receives subsidized child care, the following are your most important

responsibilities:

1. Submit true information to the CCIS.2. Report changes in a timely manner.3. Pay your family co-pay on time.

Helpful HintsAttend Your child should attend the child care program on all days assigned. If your child is absent or ill,

please call your provider.

Call Call your CCIS office if you have any questions.

Changes If there are changes that may affect your child care needs, call the CCIS office.

Pay Always pay your family co-pay on time.

Read Read all information that you receive from the CCIS office. If you do not understand or have questions, call the CCIS.

Save Save your pay stubs or the information that you get showing how much money you earn monthly. This will help you when it is time to show proof of income earned.

Tell Tell your friends about the subsidized child care program.

Transfer If you want to transfer to a new child care program, call the CCIS.

More Questions ... Who can I call if I have child care concerns?

CCIS Concerns If you have questions about child care subsidy, call your CCIS. If you are not satisfied, ask to speak to a supervisor. Your CCIS number is listed on the back of this handbook.

Subsidized Child Call the Regional Office of Child Development and Early Learning. The numbers are listed Care Concerns below.

Legal Services If you need help with an appeal, a fair hearing or you need legal advice about your eligibility for subsidized child care, call the legal services office. The number is listed on the back of this handbook.

Provider Concerns If you think something is wrong with your child care program or if you see mistreatment of a child, call the Regional Office of Child Development and Early Learning. The number is listed below.

Keystone Stars If you would like to locate a Keystone STARS provider in your area, call your CCIS. The CCIS number is listed on the back of this handbook.

Important Telephone Numbers ...

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OFFICE REGION TOLL FREE NUMBER

Office of Child Development and Early Learning

Legal Services

Central Region

Northeast Region

Southeast Region

Western Region

Statewide

1-800-222-2117

1-800-222-2108

1-800-346-2929

1-800-222-2149

1-800-322-7572

Listed on the back of this handbookCCIS Office

“The children of Pennsylvania

are the keys to tomorrow.”

Pub 549 11/15

For Legal Services call:1-800-322-7572

The Web address is:www.palegalservices.org

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This program is made possible by the

Rev. 10/1/16 CCIS R039 Things you need to know Eng 10.1.16 CCIS R 039

THINGS YOU NEED TO KNOW ABOUT SELECTING A CHILD CARE PROVIDER

Pennsylvania’s Subsidized Child Day Care System is a parent choice system. It is your responsibility to select the type of child care that is most appropriate for your child and best meets the needs of your family.

If your family is determined eligible for subsidy, you may choose an eligible child care provider from any of the types listed below. Any child care provider you choose must enter into a Provider Agreement with Child Care Information Services (CCIS) of Berks County. It is your responsibility to pay your provider the full cost of care until we meet with you face-to-face, and set a start date for your funding.

Types of Child Care: • Day Care Center, Group Day Care Home, and Family Day Care Home

• a program that must have a Certificate from the Department of Human Services to providechild care

• Relative Care - only great grandparents, grandparents, aunts, uncles, and siblings over 18years of age that do not live in the home with you• a person caring for no more than 3 children, who are not their own, in his or her home

must meet the following requirements, among others:• be 18 years of age or older• be able to provide photo ID• be able to provide proof of social security number• be able to provide proof of physical address• be able to provide proof of phone• complete 3 hour Mandated Reporter Training• complete FBI fingerprinting requirement (fee charged)• allow the CCIS to submit a child abuse clearance and criminal background check (fee

charged)• meet face-to-face with CCIS staff

If you have any questions about your child care options, or if you need help finding a child care provider, please call our office at

610-987-CCIS-(2247).

Rev. 10/1/15 CCIS R101 Family Composition - App Eng CCIS R 101 Eng

Dear Parent/Caretaker,

You must verify your family’s size and composition.

Please submit ONE of the following for all family members listed on the application and send to us along with the application, all income verification, proof of address, employment and/or training verification, and the Authorization for Information form:

Note: You do not have to submit all of the items listed for each family member.

▪ Custody orders▪ Medical records or written statement from a physician*▪ Copies of all children’s birth certificates (Children’s birth certificates must list the

parent’s name)▪ School records**

If you are unable to submit any of the above, contact the Intake Specialists:

Kristin B. – 610-987-8616 Elizabeth K. – 610-987-8619

* A medical record or statement from a physician must list the child’s birth date, the parent’sname as the parent of the child, and the address, which must match the address CCIS has forthe family.

** A school record must list the child’s birth date, the parent’s name as the parent of the child, and the address, which must match the address CCIS has for the family.

How to find aKeystone STARS program

Thousands of early learning programsacross Pennsylvania are participatingin Keystone STARS, such as:• Child care centers• Child care group homes• Family child care homes• Head Start programs• Preschool programs

Here are some ways to find aKeystone STARS program near you:• Visit

www.papromiseforchildren.com• Visit COMPASS at

www.compass.state.pa.us• Call 1-877-4-PA-KIDS

(1-877-472-5437)• Contact your local Child Care

Information Services (CCIS)agency.

Keystone STARS is made possible by thePennsylvania Department of HumanServices

Count the STARS!

As programs move up the STARSladder, they meet higher qualitystandards. For example:

Teacher requirements increase: At STAR 2, half of lead teachers

have an Associate’s degree in earlychildhood education.

At STAR 3, all lead teachers have atleast an Associate’s degree.

At STAR 4, half of lead teachershave a Bachelor’s degree; the resthave an Associate’s degree.

Classroom quality increases: At STAR 1, programs have the PA

Early Learning Standards on hand. At STAR 2, programs also use a

standardized tool (EnvironmentRating Scale - ERS) to evaluate andimprove their classroom andlearning activities.

At STAR 3 and 4, programs alsoreceive an independent evaluationusing the ERS tool.

Family communication increases: At STAR 1, families meet with the

teacher when the child enrolls. At STAR 2, teachers also provide

daily updates on the child’s activitiesand hold one teacherconference each year.

At STAR 3 & 4, teachers alsohold a second teacher conferenceeach year.

To learn more, visitwww.papromiseforchildren.com.

PPM7.11

Choose quality child care/early learning for your childthrough Keystone STARS!Choosing a child care program is a big decision. The teachers, classmates, andlearning activities will help shape what your child will become. Finding a program thatis the right fit for your child will also prepare him/her for success in school and in life.

Keystone STARS can help.

Child care, Head Start and preschool programs that participate in Keystone STARSare making a commitment to provide a quality education to your child. Programs earna STAR 1 to STAR 4 rating by meeting quality standards for:

• Teacher qualifications: Early childhood teachers have the education andknowledge to work with young children.

• Classroom and learning activities: The program has a variety of materials andactivities for each age level that makes it possible for children to learn somethingnew every day!

• Working with families: The program treats families as a partner in their children’sgrowth and development, and helps families access other community resourcesthat they may need like food assistance through WIC or health insurance throughCHIP.

• Management: A quality program has to have sound business practices to ensureyour child’s safety and learning.

Count the STARS. The higher the STAR level, the higher the quality.

When looking for a child care or afterschool program for your child,ask if they participate in Keystone STARS.For more information, visit www.papromiseforchildren.com, COMPASS atwww.compass.state.pa.us, or call 1-877-4-PA-KIDS (1-877-472-5437).

When you choose a quality childcare/early learning orafterschool program, your child:• is safe while you are at school

or work;• will be encouraged to explore

new things;• will learn important academic

skills like language andnumbers, but also how to playwell with others, followdirections, and practiceself-discipline; and

• is more likely to enterkindergarten prepared, dobetter in school, graduatehigh school and attendcollege.

Revised 8/8/17

STOP!! CALL CCIS BEFORE FILLING OUT APPLICATION IF YOU ARE RECEIVING OR HAVE RECEIVED CASH ASSISTANCE WITHIN THE LAST 60 DAYS.

PROCESSING MAY BE DELAYED IF YOU SUBMIT YOUR APPLICATION WITHOUT ALL OF THE REQUIRED DOCUMENTATION.

DID YOU REMEMBER TO: PROVIDE DOCUMENT INFORMATION THAT MUST BE DATED WITHIN THE LAST 6 WEEKS?

FILL IN ALL AREAS OF THE APPLICATION?

PROVIDE A COPY OF BIRTH CERTIFICATES FOR ALL CHILDREN LIVING IN YOUR HOUSEHOLD?

ENCLOSE EMPLOYMENT VERIFICATION FORM FOR YOU AND SPOUSE OR LIVE-IN FATHER OF CHILD(REN)?

ENCLOSE THE LAST 4 WEEKS WORTH OF PAY STUBS FOR YOU AND SPOUSE OR LIVE-IN FATHER OF CHILD(REN)?

ENCLOSE PROOF OF ANY OTHER INCOME SUCH AS SSI, CHILD SUPPORT, UNEMPLOYMENT?

ENCLOSE PROOF OF ADDRESS, i.e. UTILITY BILLS, COPY OF FULL LEASE (ALL PAGES)

SIGN IMMUNIZATION CERTIFICATE ON PAGE 4?

FILL IN, SIGN AND DATE THE AUTHORIZATION FOR INFORMATION ON PAGE 6?

SIGN AFFIDAVIT ON PAGE 7?

PLEASE ALLOW 30 DAYS TO PASS BEFORE CALLING TO CHECK ON THE STATUS OF YOUR APPLICATION.

pennsylvania application for subsidized child care · 2017-08-08 · if you want help in paying...

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