Dear Parent or Guardian:

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1 Bristol Bay Native Association Workforce Development Center Child Care Program P.O. Box 310 Dillingham, Alaska Phone or Toll Free Fax Dear Parent or Guardian: We are pleased that you are interested in applying for Child Care Assistance and hope we are able to help. To get your application file in order and establish your eligibility, please do the following: 1. Fill out the attached application completely. 2. Submit a completed Child Care Provider Registration Form (enclosed). 3. Submit ALL copies or proof of income with your application. The previous year s taxes and W-2 s and last month s pay stubs for current year and itemized fishing statements. 4. Submit proof that your children are Alaskan Native or Indian descendants (copy of children's Tribal cards or copies of the children's birth certificates and copy of parent s Tribal card) 5. Everyone in the home over 18 years old needs to sign PAGE 5; an Authorization for release of information form. 6. Submit a copy of your all your child/ren's Immunization records. PLEASE NOTE: BBNA has 30 days to determent eligibility for your case. You are responsible for all of your child care expenses unless otherwise notified by BBNA. 3. We cannot determine eligibility, until we have all the required paperwork and completed application forms. 4. A completed child care application does not automatically mean a client is eligible for child care assistance. 5. Child Care is approved from the date we receive ALL the necessary documents to determine your case. No child care is approved before that date. 1

2 Child Care Assistance The Child Care Development Fund serves individuals and families by increasing the availability, affordability, and quality of child care in the BBNA service area. APPLICATION: Client must apply for services using the Child Care Assistance Application Form. Client must choose their child care provider. A. B. The child care provider can be a relative, friend, licensed daycare home. If the client chooses a family daycare home (home that is not licensed, but can be a relative or friend) they must register with BBNA using the Child Care Provider Registration Form. The provider must be 18 or older and cannot reside in the home with the children or the client C. A licensed daycare home must provide a copy of their license for the file. D. If there is someone living in the home 18 or older, is not working, in training or in school, and is capable of caring for the children then child care cannot assist. ELIGIBILITY: A client s eligibility is based on the following criteria: A. B. C. Parent(s) must be involved in one of the following activities: working, training/education or subsistence activities. Children must be Native Descendents. (Proof can be CDIB s, Copy of parents CIDB s with copy of children s birth certificates.) Parent(s) past 12 months income must not exceed income guidelines. INCOME: Eligibility is determined by using the client s previous 12 month income OR projecting the client s current income. A. Past Net Income will be used. B. Projected net Income will be used. Please note the rate of pay BBNA will remit to the child care provider. BBNA will provide notification of the maximum number of approved hours for payment per day, anything over this is the payment responsibility of the parent. AGE Less than 8 hours Daily Rate age 0-1 yr. age 13 mo.-3 yr. age 4 yr-12 yr. $5.00/hour $4.50/hour $4.00/hour $40.00/day $36.00/day $32.00/day If you have any questions or need additional information please call our toll-free number at

3 Bristol Bay Native Association Workforce Development Today s Mailing Address: P.O. Box 310 Dillingham, AK Phone: (907) Toll Free: (888) Fax: (907) Applicant s Central Intake and Short Employability Development Plan Name: Current Age (First) (Middle) (Last) Social Security Number: - - (Also Known As - or Maiden name) Date of Birth: / / Present Mailing Address: ( P.O. Box) Present Physical Address: (Street Address) Gender: Male Female (City) (State ) (Zip Code) (City) (State ) (Zip Code) Home Phone: ( ) - Work / Cell Phone: ( ) - Address: Tribally enrolled at (please circle or indicate other ); Aleknagik, Chignik Bay, Chignik Lagoon, Chignik Lake, Clarks Point, Dillingham, Egegik, Ekuk, Ekwok, Igiugig, Iliamna, Ivanof Bay, Kanatak, King Salmon, Kokhanok, Koliganek, Levelock, Manokotak, Naknek, New Stuyahok, Newhalen, Nondalton, Pedro Bay, Perryville, Pilot Point, Port Heiden, Portage Creek, South Naknek, Togiak, Twin Hills, Ugashik or Other Marital Status: Single Single and living with significant other Married Separated Divorce Widowed Family Status: Single Individual One Parent Family Two Parent Family Number dependents under 18 Veteran? No Yes - Date of Discharge: / / Registered with Selective Service? Yes No Educational Status: High School Diploma - Year Graduated: GED-Year obtained OR Highest Grade Completed: College/Vocational Graduate - Type of Degree: AA/AAS BA/BS MA/MS Other: Year Some BBNA WFD programs and/or jobs are subject to drug testing. Are you willing to take a drug test? Yes No Applicant Ethnicity (check one) Alaskan Native Applicant Primary Goal (check one) Applicant Secondary Goal (check one) Enter postsecondary Education or Job Obtain or Improve a Job Training Retain Current Job Leave Public Assistance Educational American Indian Obtain or Improve a Job Gain Asian Retain Current Job Earn a GED or Secondary School Diploma African American Educational Gain Enter Postsecondary Education or Job Training Hispanic or Latino Earn a H.S. Diploma, GED or college Obtain United States Citizenship Skills Native Hawaiian Pacific Islander Caucasian Other: degree Subsistence Activities (carving, beading, sewing, etc.) Obtain Child Care Assistance Obtain Alaska Driver s License Increase involvement in child s education Increase involvement in child s literacy Increase involvement in community activities Subsistence Activities (carving, beading, sewing, etc.) Other: Other: I expect to meet this goal by: / / I expect to meet this goal by: / / 1

4 Bristol Bay Native Association Workforce Development Page 2 Central intake Applicant Name: Mailing Address: P.O. Box 310 Dillingham, AK 99576~ Phone: (907) ~ Toll Free: (888) ~ Fax: (907) Applicant Primary Status (Check All That Apply) Last hourly wage: Disabled $ Employed Applicant Secondary Status Institutional Programs (Check All That Apply -optional) Low Income (Check All That Apply) In Correctional Facilities Release date Homemaker Worked 90 days or more Unemployed since: this calendar year Unemployed / / Collecting unemployment Not in the Labor Force (currently on On Public Assistance or received in last six (food stamps, general months) assistance, ATAP) Living in a Rural Area Offender on Probation until Felony Misdemeanor Pregnant Single Parent On Third Party Custody Release Date Teen Parent Dislocated Worker Learning Disabled Adult In Specialized Treatment: (Substance Abuse, Behavioral Health, API etc.) release date Homeless No None of the above Transportation None of the above I certify that the information given on this application is true to the best of my knowledge. By signing my name, I agree to allow information from this form to be used for statistical and follow-up purposes. I understand that my name will never be used in any report and that all data will be kept strictly confidential. I have read, understand and been given a copy of my rights and responsibilities Yes No Signature: Signature Date: Guardian s Signature: Signature Date: Additional Skills of Applicant: check all that apply Computer Skills Commercial Driver s License Plumbing Fax Machine Copy Machine Hazwoper Certification Asbestos Certification Electrical Laborer Multi Line Phone 10 Key Calculator Carpentry Mechanic Fishing/Deckhand Child Care Provider Word Processing Excel Other: Household Members (Please list all household members) Last Name First Name MI Relationship Tribal Member of Bristol Bay Native Association Workforce Development Mailing Address: P.O. Box 310 Dillingham, AK 99576~ Date of Birth Social Security # Page 3 Central intake Applicant Name: 2

5 Phone: (907) ~ Toll Free: (888) ~ Fax: (907) Types of Income WA Wages SEA Seasonal Work/Fishing SE Self Employment DI Dividends SSI Supplemental Security Income SSA Social Security PFD Permanent Fund Dividend VB Veterans Benefits CO Cash out Retirement/Pension TT Tribal TANF WC Worker s Compensation BP Bingo/Pull Tab Winnings UI Unemployment TI Tips and Gratuity RI Rental Income FLS Family Support (Explain) GR General Relief OT Other (Explain) FC Foster Care Payments BIA BIA General Assistance SL Student Loans/Grants IN Interest CS Child Support & Alimony APA Adult Public Assistance PE Pension (other than Veteran s Benefits) Household Income (Please list all household members income) Household member name Type of Income Gross Income Form of Proof Last Day of Work Weekly/Monthly? Applicant Employer Name: Phone # Do you own home or rent? Landlord Name: Phone # I hereby certify that all information listed above is true and correct. I understand that submitting misleading or falsifying information to gain benefits are grounds to denial of services and may lead to prosecution, fines and imprisonment Signed: Date: FOR OFFICE USE ONLY Date Received: Date Entered: Initials: Consumer #: 3

6 Request for Child Care I am requesting hours of child care per day, my household, who are under age 13: days a week for the following children in 1) DOB 3) _DOB 5) DOB 2) DOB 4) _DOB 6) DOB I am in need of child care assistance because: I currently work hours per day, days a week. Place of Employment Phone # I am attending training from / / to. / /. I am enrolled in school at. I or my spouse engages in subsistence activities Support my family. My spouse works hours a day f/t p/t to help days per week Place of Employment Phone #. I have TANF requirements My chosen Provider is Applicant s Signature Witness Signature (if X ) EMERGENCY CONTACT Care will be provided: Date Phone # in provider s home in a Center in my home (In parent s home -MUST INCLUED: PARENT UNDERSTANDING FOR IN-HOME CHILD CARE FORM and IN-HOME PROVIDER CAREGIVER VERIFICATION see CCDF Program Manager for details) Bristol Bay Native Association 4

7 Workforce Development Center P.O. Box 310 Dillingham, AK Toll free: or Local: Fax: Authorization for Release of Information For Child Care assistance; everyone in the home over the age of 18 must sign. Attach another sheet if needed. I hereby authorize the release of all information needed by BBNA Workforce Development Center contained in the City Councils, Village Councils, State, and Federal, Private or Educational Agencies records to the organization listed above: This authority shall continue in effect until this client is no longer of BBNA s Workforce Development Center s Services. Furthermore, that authorization is being given to the BBNA Workforce Development Center to proceed on my behalf to provide employment assistance services included (but not limited to): 1. Referral to potential employers 2. Inclusion in a Talent Bank/Skills Survey This information is needed for verification of eligibility for: CLIENT Household member- over age 18 Household member- over age 18 CLIENT Print full name Print full name Print full CLIENT Social Security Number Social Security Number Social Security Number CLIENT Date of Birth Date of Birth Date of Birth CLIENT Signature Signature Signature Date Date Date 5

8 Bristol Bay Native Association Workforce Development Center P.O. Box 310 Dillingham, AK Toll free: or Local: Fax: Photo Release of Authorization Form I hereby consent, without further consideration or compensation, to the use (full or in part) of all photographs, digital photos or any video taping made of me during WFD/Training events and/or activities, by BBNA or the employer I will be working with. For the purposes of internet web productions to the web site or any monthly reports, newsletter, annual reports. Further, I release BBNA or any employment and/or training agency and their members from any liability which may arise from the use of those materials. I website or any of the following listed above. DO NOT want photos of myself or my family published to the district This Release will remain in full force and effect until withdrawn in writing by me. Name: Community: Position: Signature: Date: 6

9 NOTIFICATION TO CLIENT The Federal law concerning fraud states Whoever in any matter within the jurisdiction of any department or agency of the United States, knowingly and willingly 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 or uses any false writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry shall be fined not more than $10, or imprisoned not more than five years or both. Under the Privacy Act. 5 U.S.C. 552 (a) (1) (2), Workforce Development cannot give out information you give the caseworker except Workforce Development can share this information with other Federal, State, Tribal offices and programs who have some responsibility with the Workforce Development Center for which you are applying. The information can also be given to those agencies when you ask them for a job or for some other benefit and for law enforcement purposes. This can be done without your written consent. For any other person or program wanting information is in your case record and you can ask to see it. If you believe some information is inaccurate, ask your caseworker about how to change the information in the case record. This must be read and signed Printed Name of Client Client s Signature 7

10 **IMPORTANT NOTICE ABOUT YOUR RIGHTS** FAIR HEARING Any person whose application is denied or not acted upon within 30 days, or whose benefits are reduced or terminated, has a right to a hearing before the Bristol Bay Native Association. If you desire a hearing, you may request it by telephone, in person, or in writing through the Child Care Development Block Grant Program, P.O. Box 310 Dillingham, Alaska You must make your request within thirty (30) days after you receive notice of a decision on your Child Care Assistance case. B.B.N.A. is available to assist you if you request a hearing. At the hearing you may represent yourself. You may also be represented by legal counsel (e.g. Alaska Legal Services Corporation or by another person of you choice (e.g. friend or relative.)) CIVIL RIGHTS The Civil Rights Act of 1974 states No person in the United States, on the ground of race, color, or national origin, shall be excluded from participation or be denied the benefits of federal assistance. If you feel you have been discriminated against, you may file a complaint with the Bristol Bay Native Association or with the United States Department of Health and Human Services. PARENTAL CHOICES If your application is approved, you will have complete and total authority to select the type of child care you prefer and any specific child care provider, as long as the child care provider you identify meets the registration and/or State or Tribal licensing criteria, and is willing to enter into agreement with the Bristol Bay Native Association Child Care Development Block Grant Program to serve as a vendor. (Copies of the child care provider registration and the tribal licensing forms for the program can be obtained by contacting the C.C. and D.B.C. Coordinator at B.B.N.A. Social Services Department.) AGREEMENT If your household receives assistance, you must agree to the statement below. Any member of you household who deliberately breaks any rules and receives benefits to which they are not entitled to will be required to pay back the benefits received under false information and may be prosecuted. I certify that I have checked the information on the application carefully and it is true and complete of the facts according to the best of my knowledge and belief. I understand that it is against the law to make false statements and that I am subject to prosecution if I do. I understand that a B.B.N.A. representative may call my home, and may contact other people in order to verify my eligibility for assistance. I also understand that information I give may be verified by computer cross-matching with other agencies. I authorize the Alaska Department of Labor to release to the Bristol Bay Native Association, information about my eligibility for unemployment insurance and work credits. I authorize the Bristol Bay Native Association to communicate with my child care provider and other agencies on my behalf, as it relates to the Child Care Development Block Grant Program. I understand that my household can submit only one application for Child Care Assistance per year. Furthermore, I certify that this is the only application submitted from or on behalf of my household. / / Applicant Signature Witness Signature (if X ) Date 8

11 Bristol Bay Native Association Workforce Development Center Child Care Program P.O. Box 310 Dillingham, Alaska Phone or Toll Free Fax Dear Provider: We are pleased that you are interested in applying to be an approved Child Care Provider and hope we are able to help. To get your application file in order and establish your eligibility, please do the following: 1. Fill out the attached Child Care Provider Registration Form completely. 2. Submit Interested Persons Report (Criminal Background Check) for all members of the household whom are 16 years of age and older. This can be obtained through the State Troopers office, or request an Ingens Online background check from the BBNA CCDF Case Manager. * If you are providing care in the child s home you only need to submit a report for yourself. Additional approval is needed for care in child s home. 3. Submit current TB test Results. 4. Submit a copy of your Social Security Card along with the attached W-9 Form 5. Submit a copy of your business license application and payment prior to mailing off to the State of Alaska. PLEASE NOTE: to 3. BBNA has 30 days to determent eligibility for your case. Child Care is approved from the date we receive ALL the necessary documents determine your approval. Payments will not be paid before approval date. The provider must be 18 or older and cannot reside in the home with the children or the client. Please note the rate of pay BBNA will remit to the child care provider. BBNA will provide notification of the maximum number of approved hours for payment per day, anything over this is the payment responsibility of the parent. AGE Less than 8 hours age 0-1 yr. age 13 mo.-3 yr. age 4 yr-12 yr. $5.00/hour $4.50/hour $40.00/day $36.00/day $4.00/hour $32.00/day Daily Rate 9

12 If you have any questions or need additional information please call our toll-free number at

13 CHILD CARE PROVIDER APPLICATION Bristol Bay Native Association Workforce Development Center P.O. Box 310 Dillingham, Alaska (907) Fax Date Each person who provides child care for a parent or guardian receiving child care assistance from the Bristol Bay Native Association s Child Care Development Fund must complete a home visit at least once a year. THE BRISTOL BAY NATIVE ASSOCIATION RESERVES THE RIGHT TO DENY REGISTRATION AND PAYMENT TO ANY PERSON OR AGENCY WHO IS DETERMINED BY THE TRIBE TO BE A POTENTIAL DANGER TO CHILDREN BECAUSE OF CURRENT OR PAST ASSOCIATION WITH OR PARTICIPATION IN CRIMINAL ACTIVITIES, ALCOHOL OR OTHER SUBSTANCE ABUSE, COMMUNICABLE HEALTH PROBLEMS, OR UNSAFE CHILD CARE PRACTICES. THE REQUIREMENTS FOR ALL CHILD CARE PROVIDERS ARE ON PAGE 2 QUESTIONS 1-4 *If the child care provider cares for more than six children, unrelated to him/her, it is necessary that the provider be licensed by the State of Alaska Child Care Program. In this case, the provider must contact the State of Alaska Child Care Program at for licensure. You can find information, forms and applications on their web site at BBNA requires that care givers are in compliance with all State and Tribal licensing before authorization of payment. INFORMATION ABOUT THE CHILD CARE PROVIDER Name of Provider Date of Birth Social Security or other ID # Mailing address City & Zip Home Phone # Cell Phone # Physical location where care takes place if in parent s home - PARENT UNDERSTANDING FOR IN-HOME CHILD CARE FORM and IN-HOME PROVIDER CAREGIVER VERIFICATION MUST BE INCLUED Education (circle the highest)- (some HS) (HS/GED grad) ( CDA )(EC Cert) (AA) (BA )(MS) Degree major List additional education or training 11

14 I allow BBNA to provide my contact information to parents/guardians seeking child care YES NO OTHER HOUSEHOLD MEMBERS NAMES DATE OF BIRTH RELATIONSHIP TO PROVIDER SS OR ID # THE FOLLOWING IS REQUIRED: Hav e Need 1.Business Licenses Expiration date: 2.Criminal Background Checks on all members of the household over the age of 16 3.TB results Expiration date: 4.Copy of Social Security card What are your hours of care? What days will you provide care? Holidays off? What age range will you provide care for? Will you be available for drop-ins after school care Where is care provided? in my home in a Center in Client s home- (MUST INCLUED PARENT UNDERSTANDING FOR IN-HOME CHILD CARE FORM) There may be times when you are ill or need help in an emergency; two back up providers are recommended. Both providers must meet the health and safety requirements listed above (#2. & #3) Primary backup care provider Contact # Secondary backup care provider Contact # CHILD CARE HEALTH / SAFETY CHECKLIST PROVIDER Are you 18 years of age or older? Has everyone in the home; 16 years or older; obtained a Criminal Background Check? Do you fully understand that you are required by law to report suspected child abuse? Do you provide a smoke, drug and alcohol-free environment for the children in your care: this includes the child care site and vehicle used to transport children? Does each floor of the facility have at least one properly installed and maintained smoke and 12 YES NO

15 6 7 carbon monoxide detector? Is there a fire extinguisher, which is readily accessible and maintained in operable condition? Are you current on your EC First Aide / CPR certification? Expiration date: (submit copy for file) Is there a first aid kit that is in a convenient location and is inaccessible to children? Is there a list of emergency contact numbers including the parent/guardians? Is there an emergency evacuation plan? Are there at least two ways of exiting the child care area? Are poisons, toxic materials, cleaning substances, sharp or pointed objects, and guns kept in a safe place or locked up so children cannot get to them? Are all outlets covered or non-accessible to children? Are all small items checked against choking hazards? Is there a safe play area provided, including inside and outside areas? Are the floors and walls clean and maintained in a condition safe for children? Ventilation, temperature, and lighting are adequate for children s safety and comfort Are toys and objects (i.e. high chair/ crib/ etc.) safe, durable, easy to clean and non-toxic? Do you have home owners or rental insurance? Has your water quality been tested? Do you have a wood stove? If so do you have a plan to keep children from potential harm? YES CHILD S HEALTH Is all medicine, prescribed and/or over-the-counter; administered only with written parental instruction? Do you use separate towel/washcloth on each child? Do you diaper, change and toilet children away from the food preparation area? Are parents notified of any accident or injury to the child? NO How do you insure that allergies to foods/ environment are noted and observed? What form of discipline do you use? How do you keep track of the mobile children? Do you have pets? YES NO Are all pets current on rabies vaccinations? YES NO Have any of these pets harmed anyone either intentionally or by accident? YES NO Explain 13

16 How do you keep the children / pets safe from harm? List all the children you will be providing care for Date of Birth Provider relationship Name of Parent #1 (client) Parent s home # Parent s Cell # Parent s work # Name of Parent #2 Parent s home # Parent s Cell # Parent s work # Parents address City/Village State Zip code I certify that I will comply with all the requirements set forth by the Bristol Bay Native Association Child Care Development Fund Program governing the registration of child care providers and that my answers to all the questions and statements I have made on the pages of this registration are true and correct to the best of my knowledge. As a Child Care Provider, I agree to comply with the recommendations listed above. All recommendations will be followed through within 3 weeks from the date of this form. I understand that if the above recommendations are not completed within 3 weeks that my Child Care payments will be suspended until I have complied with the above requests. I allow BBNA to provide a copy of pages 1-3 of this Home Visit to clients whom are parents of the children I care for. Signature: Child Care Provider Date >Signature: Parent of Child/ren Date >Printed: Parent of Child/ren Signature: BBNA Representative Date 14

17 Printed BBNA Representative Qualifications of Persons Having Regular Contact with Children in a Child Care Facility As per 4 AAC (b) and (d) as referenced in 4 ACC (a)(3): Approved Providers An individual may not work, volunteer, or reside in a child care facility or in any other part of the premises housing a child care facility, if the individual has the opportunity to access to the child care facility and: Is the alleged perpetrator of an incident of child abuse or neglect in which the department of Health and Social Services found the evidence available substantiates the allegation, or the information available to the department demonstrates to the department the individual s inability to adequately provide care and supervision to children: Has a physical, health, mental health or behavioral problem to an extent that the problem poses a significant risk to the health, safety, or well-being of children in care: Has a domestic violence or alcohol or other substance abuse problem to an extent that the problem poses a significant risk to the health, safety or well-being of children in care: Was the subject of prior adverse licensing action: Subject to the Barrier Crimes requirements as listed by the Barrier Crimes Matrix listed in 7 AAC AAC at the web site: Was, at any time, under indictment, charged by information or complaint, or convicted of any of the following offenses: * An offense against the family and vulnerable adults * Perjury under AS * A serious offense For a list of Barrier Crime offenses please request a copy from the Child Care Coordinator. I have read and understand the above statement. Signature Date 15

18 Bristol Bay Native Association Child Care Provider Reference This is a reference for which I have known for Child Care Provider s Name in the capacity of Year, Months (Friend, Co-worker, Employer, etc.) I know this person: Very Not an immediate Relative Well Casually Not well enough to give a reference Please answer the following questions: 1. Does this provider show any serious health, alcohol or drug problems? If yes, please explain: Yes NO 2. Can you attest to the good character, maturity and sound judgment of this provider? Yes No If no please explain: 3. How would you assess the Providers ability to provide good care to children? Check one: Excellent Good Fair Poor 4. List those qualities, which you believe will enable the provider to work successfully (or unsuccessfully) 5. If you needed a Child Care Provider, how would you feel about leaving your children with this Provider? Very enthusiastic somewhat enthusiastic Worried Would NOT Comments: Print Name of Reference Signature of Reference Date Telephone Number 16

19 Address of Reference City State Zip Code Bristol Bay Native Association Child Care Provider Reference This is a reference for which I have known for Child Care Provider s Name in the capacity of Year, Months (Friend, Co-worker, Employer, etc.) I know this person: Very Not a Relative Well Casually Not well enough to give a reference Please answer the following questions: 1. Does this provider show any serious health, alcohol or drug problems? If yes, please explain: Yes NO 2. Can you attest to the good character, maturity and sound judgment of this provider? Yes No If no please explain: 5. How would you assess the Providers ability to provide good care to children? Check one: Excellent Good Fair Poor 6. List those qualities, which you believe will enable the provider to work successfully (or unsuccessfully) 5. If you needed a Child Care Provider, how would you feel about leaving your children with this Provider? Very enthusiastic somewhat enthusiastic Worried Would NOT Comments: Print Name of Reference Signature of Reference Date Telephone Number 17

20 Address of Reference City State Zip Code Notification to Child Care Provider The Federal law concerning fraud state Whoever, in any matter within the jurisdiction of any department or agency of the United Stated, knowingly and willingly 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 or uses any false writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry shall be fined not more than $10, or imprisoned not more than five years or both. Under the Privacy Act 5 U.S.C. 552 (a) (1) (2), Workforce Development cannot give out the information you give the caseworker except Workforce Development can share this information with other Federal, State, Tribal offices and programs who have some responsibility with the Workforce Development for which you are applying. The information can also be given to those agencies when you ask them for a job or for some other benefit and for law enforcement purposes. This can be done without your written consent. For any other person or program wanting information is in your case record and you can change the information in the case record. This must be read and signed Child Care Provider s Signature Printed Name of Child Care Provider 18

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