We have enclosed the instructions and forms for you to complete and information regarding the minimum requirements for listed family homes.

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1 Dear Potential Relative Child Care Provider, The Texas Workforce Commission adopted a ruling which states a relative providing child care in the relative s residence must be listed with the Texas Department of Family Protective Services (DFPS) to be an eligible relative provider with Workforce Solutions Northeast Texas. Relative providers must provide Workforce Solutions Northeast Texas with a copy of a listing permit issued by DFPS before child care assistance can be approved. We have enclosed the instructions and forms for you to complete and information regarding the minimum requirements for listed family homes. Please follow the instructions exactly to assure that your listing application is processed. DFPS has stated that processing could take 45 days or more. As soon as you receive your listing certificate from DFPS, please mail or fax us a copy. At that time, we will mail you our Relative Provider eligibility packet to complete and return. If you have any questions, please contact our office. Respectfully, Workforce Solutions Northeast Texas Child Care Services

2 MAILING INSTRUCTIONS FOR LISTED FAMILY HOME APPLICATIONS 1. Mail application (Form 2986-Listing Request), Background Checks (Form 2971) & a copy of your check or money order to the following address: Texas Dept. of Family & Protective Services Attn: Debra Goza, Listed Family Home Technician Child Care Licensing 8700 N. Stemmons Frwy. Dallas, TX A background check is required for everyone 14 years and older in your home. Fill out one section for each individual. Debra will contact you either by phone or letter and give you an operation number. Do not mail payment to Austin prior to obtaining the operation number. This number must be printed on your check and your fee payment form or the money will not be credited to your (child care) operation. 2. Mail payment (check or money order) (NO CASH) along w/fee schedule (Form 2988) to the following address or use the enclosed envelope after obtaining the operation number and putting the operation number on your fee payment form and payment: Texas Dept. of Protective & Regulatory Services Licensing Fee Accounting Division E-672 P. O. Box Austin, TX Enclosures: The other information included in this packet is useful information to a child care provider. Also included are the laws associated with child care.

3 Requirements for Listed Family Homes The Texas Workforce Commission requires that relatives who care for a child in the relative s home be listed with the Department of Family and Protective Services (DFPS) in order to be eligible to be reimbursed for providing child care services. Once listed with DFPS, you will be required to comply with DFPS rules and all provisions of Chapter 42 of the Texas Human Resources Code (the child care licensing law) that apply to listed family homes. Additionally, information about your listed family home will be posted on the DFPS Web site and you could receive inquiries from individuals needing a caregiver for their child. As a listed family home, you must be aware of and comply with the DFPS requirements for listed family homes outlined below. The following caregivers are required to list with DFPS: An individual at least 18 years old who provides care for compensation for three or fewer children, ages birth through 13 years, who are unrelated to the caregiver. The care is provided for at least four hours a day, three or more days a week, and for more than nine consecutive weeks. Total number of children in care: The total number of children in care, including children related to the caregiver, may not exceed 12*. A caregiver who is subject to regulation as a listed family home and wishes to care for more than three children unrelated to the caregiver must instead become a registered child care home. *Note: Your Local Workforce Development Board may have a local policy limiting the number of subsidized children you can care for. Annual Fee Renewal: You are required to pay an annual fee of $20. DFPS will notify you when your annual fee is due. Failure to pay the annual fee will result in revocation of the listing permit and you will not be allowed to receive a subsidy for providing child care services. There are no additional fees for the background check requirements described below. Background Check Requirements: You must continue to submit background check information, using the Request for Criminal History and Central Registry Check, Form 2971, for the following: Individuals who regularly or frequently work or live in the home and are turning 14 years of age; and New individuals regularly or frequently working or living in the home. WD Letter 50-07, Attachment 3

4 Background check information for these individuals must be submitted within two business days after the individual turns 14 years of age or is newly present in the home. You must resubmit background check requests for all individuals once every 24 months after you first submit an individual s name to DFPS. Required Notification to DFPS: You are required to notify DFPS if you move or close your family home. WD Letter 50-07, Attachment 2 2

5 Instructions for Relative Child Care Providers on Completing Required Texas Department of Family and Protective Services Forms General Instructions: You must submit the following forms to the Texas Department of Family and Protective Services (DFPS) Local Child Care Licensing Office: Listing Request, Form 2986; and Request for Criminal History and Central Registry Check, Form You must submit the following form, along with a $20 application fee, to the DFPS Accounting Division in Austin, Texas (address provided in detailed instructions below): Child Care Fee Schedule, Form The forms must be filled out completely. Any form not fully completed will be returned to you, and DFPS will not process your application until all of the requested information is provided. Listing Request, Form 2986 General Instructions: Do not leave any blanks. Write none, not applicable, or NA if an item does not apply. If the question is a required yes or no question, check either Yes or No; do not leave the answer blank. Your Information: Provide your name, address (including mailing address), telephone number, date of birth, Social Security number, and Texas Driver s License number. Note: For Social Security number and Texas Driver s License number, indicate if you do not have a Social Security number or a Texas Driver s License, or if your driver s license is out-ofstate. 1. List each individual 14 years of age or older who will regularly or frequently be present, staying, or working at the home while the children are in care. Important: Submit the Request for Criminal History and Central Registry Check, Form 2971, on yourself, and all individuals listed in question #1 of the Listing Request, Form Check either Yes or No if other individuals not listed in #1 will assist you in caring for children in the home. If Yes, provide each individual s name, address, telephone number, Social Security number, and Texas Driver s License number (if available). Add these individuals to the Request for Criminal History and Central Registry Check, Form Important: Although other individuals may assist you in caring for an eligible child, the Texas Workforce Commission and the Local Workforce Development Board cannot reimburse those individuals. Additionally, you must be present in the home when those individuals provide care. WD Letter 50-07, Attachment 2

6 3A. Check Yes to indicate that you are requesting to be listed in order to receive a federal child care subsidy. 3B-C. Indicate whether you are caring for children who are not related to you and the number of related and unrelated children you are caring for or intend to care for. 4. Check either Yes or No if you have ever been licensed, registered, or listed as a child care provider by any agency of the State of Texas. If Yes, provide information on your previous license or registration. 5. Information for the DFPS Web site is required. Information regarding your operation and its compliance history will be posted on the DFPS Web site. However, the information requested in Services Offered and Directions to Location under this question is optional. Signature and Date: You must sign and date the form. Mailing Instructions: Mail this form to your DFPS Local Licensing Office. Texas Workforce Center staff can provide you a list of addresses for DFPS Local Child Care Licensing Offices. Request for Criminal History and Central Registry Check, Form 2971 General Instructions: Do not leave any blanks. Write none, not applicable, or N/A if an item does not apply. If the question is a required yes or no question, check either Yes or No; do not leave the answer blank. Your Information: Provide your name as the Operation Name. This must be the same name as appears on the Listing Request, Form Write N/A for the Operation Number. This number will be provided to you upon approval of your listing permit by DFPS. Provide the street address, mailing address, county, and telephone number that you provided on the Listing Request, Form Signature and Date: You must sign and date this form. Individuals for Whom a Background Check Is Requested: Complete information for yourself and each individual listed in questions #1 and #2 on the Listing Request, Form Note: This form provides the space necessary for information on up to three individuals. Fill out as many copies of page two as necessary if there are more than three individuals requiring a background check. Indicate that this is an Initial background check. Provide the Social Security number and Texas Driver s License or other ID number. Provide the individual s name as it appears on the Listing Request, Form Provide the individual s street address, county, and telephone number. Provide the individual s date of birth and gender. WD Letter 50-07, Attachment 2 2

7 List every town and city in Texas where the individual has lived since the age of 14. Provide the date when the individual began living in or frequenting your home. Provide the race and ethnicity of the individual. Provide all other names (married, maiden, etc.,) that the individual may have used. Mailing Instructions: Mail this form to your DFPS Local Licensing Office. Texas Workforce Center staff can provide you a list of addresses for DFPS Local Child Care Licensing Offices. Child Care Fee Schedule, Form 2988 Your Information: Provide your name as the Operation Name. This must be the same name as appears on the Listing Request, Form Write N/A for the Operation Number. This number will be provided to you upon approval of your listing permit by DFPS. Provide the street address, mailing address, county, and telephone number that you provided on the Listing Request, Form Provide the DFPS District i.e., the areas, Central Texas, North Texas, etc., specified on the list of addresses for DFPS Local Child Care Licensing Offices. Texas Workforce Center staff can provide this list to you. Type of Fee Being Paid: Check the Listing Request Fee box. Write $20 in the space provided. Total Amount of Fees Paid: $20. Note: This $20 fee includes the background check and you are not required to pay any additional fees for multiple background checks. Mailing Instructions: Do not send cash. Personal checks are accepted. Make checks payable to the Texas Department of Family and Protective Services. Attach the $20 fee to your completed Child Care Fee Schedule, Form 2988, and mail it to the address below. This is the only form that you mail to this address. All other forms must be mailed to your DFPS Local Child Care Licensing Office. Texas Department of Family and Protective Services Accounting Division E-672 P.O. Box Austin, Texas You are encouraged to keep a copy of the completed forms and payment information for your records. WD Letter 50-07, Attachment 2 3

8 Texas Dept of Family Form 2986 and Protective Services LISTING REQUEST July 2007 Texas law gives you the right to know what information is collected about you by means of a form you submit to a state government agency. You can receive and review this information, and request that incorrect information about you be corrected by contacting your licensing representative. Name (last, first, middle) Social Security No.* Tx. Driver s Lic. No.* Date of Birth Other names I have used or have been known by (maiden, married, etc.) / / Street Address (if rural, attach directions) City County Zip Mailing Address (if different) -- Street or P.O. Box City County Zip Telephone No. (include A/C) *Indicate if you do not have a Social Security number or a Texas driver s license or if your driver s license is out-of-state 1. The following people (spouse, children, friends, etc.) live in my home with me or are regularly or frequently present while children are in my care: NAME (last, first, middle) AGE DATE OF BIRTH SOCIAL SECURITY NO.* TX. DRIVER S LICENSE NO.* RELATIONSHIP *Indicate if none. 2. Will any other people assist you in caring for children? YES NO If Yes, provide the following information on the people who will assist you (include their names on Form 2971): Name (last, first, middle) Social Security No.* Tx. Driver s Lic. No.* Date of Birth Address - Street City Zip Telephone No. (A/C) Name (last, first, middle) Social Security No.* Tx. Driver s Lic. No.* Date of Birth Address - Street City Zip Telephone No. (A/C) 3. A. Are you requesting to be listed in order to receive a federal child-care subsidy? YES NO B. Are you now caring for children in your home who are not related to you? YES NO C. How many children are you caring for or do you intend to care for? (related), (unrelated). 1 of 3

9 Texas Dept of Family Form 2986 and Protective Services July Has any agency of the State of Texas ever licensed, registered, or listed you to care for children? YES NO If yes, when were you licensed/registered/listed? Address (Street, City, Zip) County(ies) If licensed/registered or listed under another name(s), list name(s): 5. TDFPS posts information about your operation and its compliance history on our public web site at If your address, phone or other information changes, please inform your local licensing office. INFORMATION FOR TDFPS WEB SITE Phone #: ( ) Fax #: ( ) Address: Web Page Address: Pager # ( ) Cell Phone.# ( ) OPERATION: (Please check all that apply) Hours of operation: Begin time End time Days of operation: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Months of Operation: Year round or January February March April May June July August September October November December Ages Served: Infants (birth -17 months) Toddlers (18 months 2 years) Pre-kindergartnen (3 years 4 years) School-age (5 yrs and older) SERVICES OFFERRED: (Please check all that apply): Child and Adult Care Food Program Subsidized Child Care After-School Care Part-Time Care Get Well Care Special Skills Classes (will enroll children for only part of the day and/or week) (for ill or recovering children) Drop-In Care (Alternate Care) Special Needs Care Program Water Activities Accredited by National Organization Wheelchair Accessible Pool on Premises Employer-based Child Care (open only to employees) Language (primary language spoken in the facility) Please enter DIRECTIONS TO LOCATION: (Please give clear concise directions) Educational Program for Pre- Kindergarten Educational Program for Kindergarten and Above Transportation Field Trips If you wish to provide additional information, please contact your licensing representative. NOTE: Persons requesting listing have the option of attending a child-care orientation in health, safety, and sanitation related to preventing risk to children. Contact your local licensing office for more information. Information contained in this Request may be required by law to be released to the public. 2 of 3

10 Texas Dept of Family Form 2986 and Protective Services July 2007 FOR DFPS USE ONLY Criminal History Central Registry Date Received Date Entered Date Completed Date Received Date Entered Date Completed Date Request Rec d Date Accepted Date Fee Verified Amount Paid Method of Verification By: I request to list with the Texas Department of Family and Protective Services to provide child care. I agree to comply with the Department s rules and all provisions of Chapter 42 of the Human Resources Code (the child care licensing law) that apply to listed family homes. I understand I am to notify the Texas Department of Family and Protective Services if I move or when I am no longer caring for children. I also certify that the information I have given contains no willful misrepresentation or falsification and that it is true and complete to the best of my knowledge and belief. I understand that any willful misrepresentation is cause for immediate denial or revocation of my listing. I authorize the Texas Department of Family and Protective Services to contact people listed on this form. I authorize the Texas Department of Public Safety to release my criminal history record information to the Texas Department of Family and Protective Services. Signature Date 3 of 3

11 Texas Dept of Family REQUEST FOR CRIMINAL HISTORY Form 2971 and Protective Services AND CENTRAL REGISTRY CHECK Texas law gives you the right to know what information is collected about you by means of a form you submit to a state government agency. You can receive and review this information, and request that incorrect information about you be corrected by contacting your licensing representative. Operation Name Operation Number Telephone No. (A/C) October 2006 Pg. 1 of 2 Operation Address (Street, City, ZIP) Operation Mailing Address (City & Zip) County Chapter 42 of the Human Resources Code requires the director, owner or operator of a child care facility or family home to provide identifying information on the director, owner and/or operator, each employee and each person 14 years of age or older who will regularly or frequently be staying or working at the facility or home while the children are in care (other than a child in care at the facility or home). This information will be used to check for any criminal history that is a violation of minimum standards and the Department s central registry of abuse and neglect. It may be necessary for you to obtain additional information if the person does not live in Texas or may have a criminal history in another state. The criminal history and central registry checks are not intended to delay hiring new staff. You will be notified of the results of the check. I verified (by looking at the person s social security card and/or driver license) that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge. I understand that the Department may contact others and, at any time, seek proof of any information contained here. I understand that any willful misrepresentation or failure to provide identifying information within the stated time limit is a cause for denial of the application or revocation of my license, registration or listing. Signature of Director, Owner, or Operator Date Complete the following for each person requiring a Criminal History/Central Registry Check; verify that the information is accurate by checking the person s social security card and/or driver license; and return all required background check request forms to your local licensing office. All names used currently or in the past by the person must be entered. Without these names you may get cleared results when there is actually a match. If a new person is being hired you must submit the request TO YOUR LOCAL LICENSING OFFICE WITHIN TWO DAYS after the person is hired or is present in the operation. Requests for background checks may be submitted by mail or through the TDFPS Internet at the following address: If you are submitting your request through the Internet please DO NOT submit this form to your licensing office. If you are not submitting your request through the Internet the background check request form must be submitted to YOUR LOCAL LICENSING OFFICE. Additional copies of this forms may be obtained on the DFPS web site. For each person listed on this form or submitted through the Internet, a $2 fee must be paid. A Form 2988-A, Child Care Fee Schedule, along with the fee(s), must be submitted to: TDFPS, Accounting Division E-672, P.O. Box , Austin, TX Failure to submit fee payments can result in adverse action including suspension or revocation. Initial 24 Month Check FBI Check Required Social Security Number ID Type - Drivers License or ID Number -State First Name Middle Name Last Name Street Address City State Zip County Telephone No. (A/C) Date of Birth Gender M You must list all other cities in Texas where there has been residency. If you lived outside of Texas in the previous 5 years you must also list previous address(es) outside of Texas, including the county: Relationship of person to requestor Adoptive Parent Staff Other Staff Other Caregiver Foster parent Licensed Administrator F Director Household Member Volunteer Date Hired /Used by the Operation/Agency Ethnicity (must accompany race) Race White Asian/Pacific Islander Hispanic Other Black American Indian/Alaskan Native Other names used (married, maiden, etc.) First Name Middle Name Last Name Worker Name--Last, first Mail Code District Operation No. Operation Type DFPS Use Only Date Received Date Criminal History Entered Date Central Registry Checked Date FBI Card Submitted

12 Dept of Family REQUEST FOR CRIMINAL HISTORY Form 2971 and Protective Services AND CENTRAL REGISTRY CHECK October 2006 Pg. 2 of 2 Complete the following for each person requiring a Criminal History/Central Registry Check and return this form to the Licensing Office. Additional forms may be obtained from the Licensing office. Initial 24 Month Check FBI Check Required Social Security Number First Name Middle Name Last Name ID Type - Drivers License or ID Number - State Street Address City State Zip County Telephone No. (A/C) Date of Birth Gender M You must list all other cities in Texas where there has been residency. If you lived outside of Texas in the previous 5 years you must also list previous address(es) outside of Texas, including the county: Relationship of person to requestor Adoptive Parent Staff Other Staff Other Caregiver Foster parent Licensed Administrator F Director Household Member Volunteer Date Hired /Used by the Operation/Agency Ethnicity (must accompany race) Race White Asian/Pacific Islander Hispanic Other Black American Indian/Alaskan Native Other names used (married, maiden, etc.) First Name Middle Name Last Name Initial 24 Month Check FBI Check Required Social Security Number ID Type - Drivers License or ID Number - State First Name Middle Name Last Name Street Address City State Zip County Telephone No. (A/C) Date of Birth Gender M You must list all other cities in Texas where there has been residency. If you lived outside of Texas in the previous 5 years you must also list previous address(es) outside of Texas, including the county: Relationship of person to requestor Adoptive Parent Staff Other Staff Other Caregiver Foster parent Licensed Administrator F Director Household Member Volunteer Date Hired /Used by the Operation/Agency Ethnicity (must accompany race) Race White Asian/Pacific Islander Hispanic Other Black American Indian/Alaskan Native Other names used (married, maiden, etc.) First Name Middle Name Last Name

13 Texas Dept of Family and Protective Services Please check if this is a change of address. Operation Name (if Registered Child Care or Listed Family Home, enter your name only): CHILD CARE FEE SCHEDULE Form 2988 January 2007 Operation No. (on your permit): Operation Street Address: City: County: Zip TYPE OF FEE BEING PAID NOTE: This form must be attached to all child-care fee payments submitted to DFPS accounting division. Payments received without this form may delay proper processing of your payment. If your payment is not properly processed it will be shown as unpaid and can result in adverse action taken against your operation including suspension or revocation. RETURN ONLY THIS FORM WITH YOUR LICENSING FEE PAYMENT IN THE RETURN ENVELOPE ADDRESSED TO: DFPS Accounting Division E-672, P.O. Box , Austin, Texas PAC-610 OBJ All other forms should be mailed directly to your local Licensing Office District Telephone Number - - AMOUNT FOR LISTED FAMILY HOMES ONLY: Listed Family Home Fee: A $20 fee paid when the listing is requested and at the anniversary date of issuance. The background check fees are included in this. Listing Request Fee Annual Listing Renewal Fee $ FOR REGISTERED CHILD-CARE HOMES ONLY: Registered Child-Care Home Fee: A $35 fee paid when the registration is requested and at the anniversary date of issuance. Registration Request Fee Annual Registration Renewal Fee $ LICENSED OPERATIONS: Please refer to the description below for the types of fees: Operation Type (check one) Fee Type (check all that apply) Licensed Care Center Licensed Care Home Child-Placing Agency Foster Family Home Foster Group Home Residential Treatment Center General Residential Operation Maternity Homes Application Initial Initial Renewal Non-expiring license fee Annual Renewal Amendment Supplemental CAPACITY. Number of children for which you are or will be licensed: x $1 (This applies to those licensed operations that are obtaining their non-expiring license or paying annual renewal fees: it does not apply to centers that are applying/paying for application and initial license.) Maternity homes: Number of children for which you are or will be Licensed: x $2 Is this a change in the number of children from your previous Licensing? Yes No APPLIES TO ALL OPERATIONS EXCEPT LISTED FAMILY HOMES: Background Check Fee Number of Persons being checked: x $2 Amount of Fee paid: plus additional fee, if applicable Total Capacity Fee: $ $ $ Total amount of Background Check Fees: $ TOTAL AMOUNT OF FEES PAID: $ Check if you would like to receive the Texas Child Care quarterly journal at no cost. This information is needed to determine postage rates. FEE DEFINITIONS Application Fee: A nonrefundable fee of $35 for an initial application for a license to operate a child care operation, child-placing agency or maternity home. This fee is paid when the application is submitted. Initial License Fee: A $35 fee for a child care operation (other than a child-placing agency and maternity home). A $50 fee for a child-placing agency and maternity home. This fee is paid when the application is submitted. Initial Renewal: $35.00 fee for a child care operation. A $50 fee for a child-placing agency and maternity home. The fee is paid when the initial license is renewed. Non-expiring licensing fee and annual fee: A $35 fee for a child care operation plus $1 for each child the operation is licensed to serve (other than a childplacing agency and maternity home); a $100 fee for a child-placing agency; a $50 fee for maternity home plus $2 for each child the home is licensed to serve. This fee is paid before the non-expiring license is issued and at the anniversary date of issuance. Amendment License Fee (for increase in licensed capacity ONLY): A $1 fee for each child that the current licensed capacity is increased (other than maternity homes; for maternity homes an amendment fee of $2 is required for each client that the current licensed capacity is increased.) Registered Child-Care Home Fee: A $35 fee paid when the registration is requested and at the anniversary date of issuance. Listed Family Home Fee: A $20 fee paid when the listing is requested and at the anniversary date of issuance. This includes the Background check fees. Background Check Fee: $2.00 per person submitted. (The Background Check fee(s) must be submitted with this form to the address below. The Form 2971, Request for Criminal History and Central Registry Check, must be submitted separately to your local licensing office.) Exemption: Certified or state-run operations are exempt from fees. Independent Licensed Foster Family and Foster Group Homes and Non-Profit 24-hour Care Operations that charge no fees for their services or Non-Profit Operations that provide residential care for children in the managing conservatorship of DFPS during the 12-month period immediately preceding the annual anniversary of the permit must pay application fees but are exempt from paying all other fees. Make Payable To: Department of Family and Protective Services KEEP YOUR RECEIPT STUB OR CANCELED CHECK NO RECEIPT WILL BE SENT - DO NOT SEND CASH