REDETERMINATION BY MAIL PACKET

REDETERMINATION BY MAIL PACKET Dear Parent/Guardian: You have been selected to submit your childcare application by mail. Enclosed are all the forms you need to complete and sign. These forms are also available on our website: Please check each box below as you complete each form. SECTION A: Forms Packet 1. Child Care Application 2. Child Support Statement 3. Terms and Conditions 4. Verification of Employment(if paid by cash/personal check) 5. Address Change Request (if applicable), available on our website SECTION B: Documents Proof of residence (e.g. utility bill, lease, government issued document, etc.) Gross income from all sources including but not limited to: Pay stubs with gross income and hours worked If you are paid: 1. Weekly Attach your last six (6) pay stubs* 2. Bi-weekly Attach your last three (3) pay stubs* 3. Monthly Attach your last two (2) pay stubs* 4. Twice monthly Attach your last four (4) pay stubs* 5. Cash/personal check Attach Verification of Employment form filled out by your employer with your name, date current employment began, hours worked, and gross income before deductions for each pay period during the last consecutive six weeks of employment. The statement must have the employer s name, address and phone number. 6. Self-employed - Current year tax return or 1099 and accounting records with work calendar showing hours worked for the last 6 consecutive current weeks (Review self-employment income documentation sheet) Child Support & Alimony payments, Divorce decree if applicable Award letter for benefits (e.g. TANF, Food Stamps, Relative Caregiver, Social Security, SSI, Unemployment, etc.) For parents attending school, please submit schedule to include name, hours & current enrollments dates and financial aid printout Please take a moment and check each box to ensure that you have completed and signed each form and included any additional needed information. ELCIRMO reserves the right to request additional documentation. Your documents will be reviewed and you will be sent written notification of your status for continued childcare services. If you are not eligible to continue childcare services you will be sent a notice of ineligibility. Page 1 of 5

REDETERMINATION BY MAIL PACKET SECTION C: Family Needs Information FAMILY NEEDS SURVEY: A variety of literature is available to you. Please circle any topics of interest. Sleeping information Child Development Stages Recognizing Child Abuse Community Resources Toileting Information Brain Development Domestic Violence Work/Employment Info Eating Habits Language Development Special Needs GED Building Self-esteem Social/Emotional ADD / ADHD Childcare Licensing Standards Discipline, Behavioral Problems Separation Anxiety Safety in the Home Provided via SECTION D: Compliance THE COMPLETED PACKET WITH REQUIRED DOCUMENTS SHOULD BE DROPPED OFF AT YOUR LOCAL EARLY LEARNING COALITION OFFICE BY THE DEADLINE. REMEMBER, FAILURE TO COMPLY AND RETURN INFORMATION COULD RESULT IN TERMINATION OF YOUR CHILD CARE SERVICES Thank you for your cooperation. Page 1 of 5

CHILD CARE APPLICATION Changes must be reported within 10 calendar days. PARENT/GUARDIAN INFORMATION / INFORMACIÓN DEL PADRE/GUARDIÁN #1 Last Name/Apellido First Name/Nombre #2 Last Name/Apellido First Name/Nombre Legal marital status/ Estado civil legal: Single/Sotero(a)/Never married Married/Casado(a) Separated/Separado(a) Widowed/Viudo(a Divorced/Divorciado(a) Residential Address/Dirección residencial: Mailing Address /Dirección postal: Home Phone: Cell number: Email: Teléfono de casa Número de cellular Correo electrónico HOUSEHOLD INFORMATION / INFORMACIÓN DEL HOGAR How many people live in your house (boyfriend, girlfriend, child over 18, etc.): Adults Children Número de personas en su hogar (novio/a, hijo/a mayor de 18 años, etc.): Adultos Niños ELCIRMO USE ONLY List everyone living in household Relationship Birth Date Included in # Enumere pronombre que habitan en su hogar Relación Fecha de Nacimiento household 2 yes no 3 yes no 4 yes no 5 yes no PURPOSE OF CARE: Your School Readiness services must be justified by documented employment, school attendance, disability or a current referral from an authorized state agency for every adult in the household. PROPÓSITO DE LA ATENCIÓN: Sus servicios de preparación escolar deben estar justificadas por empleo documentado, asistencia escolar, discapacidad o una derivación actuales de una agencia estatal autorizado para todos los adultos en el hogar. Employer or School Name, Address & Phone Number Nombre de Empleador/Colegio, Dirección y Número de Teléfono Number of hours weekly / Número de horas por semana Rate of pay per hour / Cuanto le pagan por hora Tips Propinas Name of family member Nombre del miembro familiar ALL OTHER INCOME: Including child support, alimony, social security, TANF, food stamps, worker s comp, retirement, etc. Todos los otros ingresos: Incluido Manutención de los Hijos, Pensión de Divorcio, Seguro Social, TANF, Sellos de Comida, compensación del trabajador, Pensión de Retirado, etc. Type of Income Tipo de Ingreso Amount Cantidad Frequency Frecuencia Name of family member Nombre del miembro familiar I hereby certify that the information provided above is correct. I understand that if I give false information my case may be referred to the Florida Department of Financial Services, Public Assistance Fraud for action. Applicant Signature/Firma del Cliente Certifico que la información provista es correcta. Entiendo que si proveo información falsa, mi caso podrá ser referido al Departamento de Servicios Financieros, Fraude de Asistencia Publica, para acción. Date/Fecha Page 3 of 5

CHILD SUPPORT STATEMENT Declaración de Manutención Select one of the statements listed below based on support for each child in the household I hereby certify that I DO receive child support for the following children: Proof of child support must be provided for the last 6 weeks Written statement from absent parent, check stubs, document from Clerk of Court, or print out from www.myfloridacounty.com Child s Name Absent Parent's Name I hereby certify that the court has ordered child Support for the following children. (Proof of child support must be provided for the last 6 weeks Check stubs, document from Clerk of Court, or print out from www.myfloridacounty.com) Child s Name Absent Parent's Name I hereby certify that I DO NOT receive child support for the following children: Child s Name Absent Parent's Name I agree to notify the Early Learning Coalition within ten (10) calendar days if my situation changes in any way. This statement serves two purposes. First, it shows that ELCIRMO addressed the issue of child support, and second, should the information provided later show to be false, then this document can be used to establish the parent/guardian misrepresented their circumstances. If I provide false information, I am liable for penalty of perjury, which is a first degree misdemeanor, punishable by a definite term of imprisonment, not exceeding one year and/or a fine not exceeding $1,000 pursuant to ss.837.012, or 775.082, or 775.083, Florida Statutes. Client s Signature / Firma del Cliente Seleccione la declaración que describe la manutención de cada niño en su familia: Yo certifico que recibo manutención para el siguente/s niño/os: Prueba de pago de manutención por las últimas seis semanasdeclaración del padre ausente, copias de cheques/ money orders, documentos de la corte o impreso del historial de pagos de www.myfloridacounty.com Nombre del Niño/s Padre Ausente Yo certifico que la corte ha ordenado manutención para el siguiente/s niño/s; (Prueba de pago de manutención por las últimas seis semanas- declaración del padre ausente, copias de cheques/money orders, documentos de la corte o impreso del historial de pagos de www.myfloridacounty.com) Nombre del Niño/s Padre Ausente Yo certifico que no recibo manutención por el siguiente/s niño/s: Nombre del Niño/s Padre Ausente Yo estoy de acuerdo en notificar a Early Learning Coalition en diez (10) días si la situación cambia en alguna forma. Esta declaración tiene dos propósitos. Primero, demostrar que ELCIRMO discutió la manutención, y segundo, si la información declarada es falsa, entonces este documento servirá para establecer falsa representación del padre/guardián de estas circunstancias. Si yo reporto información falsa, estoy expuesto a una pena de perjurio, la cuales una falta de primer grado, y castigable con un término de encarcelamientoque no excede un año y/o una multa que no excede $1,000, según Estatutos dela Florida ss.837.012 o 775.083. Date / Fecha Page 4 of 5

Please initial each item to verify agreement. TERMS AND CONDITIONS I am responsible for the assessed parent fee payment to the Child Care Provider along with all other fees such as registration, materials, supplies or a difference in private pay, if any. Foster parents or long-term relative caregivers of DCF referred at-risk children are only responsible for the assessed parent fee payment to the Child Care Provider. Non- payment of parent fees could result in termination of child care services. It is my responsibility to determine the costs of receiving services from the provider I chose. I understand my child care services will be terminated if I do not re-determine eligibility on or before the re-determination date. I agree to report any changes in income and other household circumstances immediately, no later than 10 calendar days, after the occurrence. In cases of suspected fraud, referral shall be made to the Florida Department of Financial Services (FDFS). I certify that I have selected the provider of my choice and understand that I have the right to visit my child(ren) while they are in care. I understand that if my child(ren) has been referred for child care by DCF or Devereux, my provider must contact DCF or Devereux when my child is absent in compliance with the Rilya Wilson Act. I am responsible to provide the preschool with my child s current immunization and physical records. I understand my child is expected to attend my chosen program every day and that 5 consecutive unexcused days of absence may result in dismissal from the program. I will participate in Parent Involvement activities offered by the child care provider. I understand I can change my child care provider at any time, but a Provider Transfer Form must be obtained from the current provider and submitted to ELCIRMO prior to transferring to another provider. I understand that I will be responsible for the full cost of care until the transfer has been authorized by ELCIRMO. I certify the information given in the application is true and complete to the best of my knowledge. If I knowingly give wrong information or fail to update any of the listed information, I am liable for prosecution under state law. In cases of suspected fraud, referral shall be made to the Florida Department of Financial Services (FDFS). The child care agency has the right to initiate and/or receive data either through direct contact or an automated data exchange process to establish the validity of household information provided by the applicant/recipient to receive program benefits. This will include but not necessarily be limited to: social security benefits, birth dates, immunization status and/or all sources of potential and reported earned and unearned income sources. (Employment records, unemployment benefits, TANF, Child Support, etc.) I have the right to confidentiality of child information and the right to inspect, review and request a copy of his or her School Readiness record. I understand discrimination is illegal and that I will not be denied services because of race, ethnic background, color, creed, national origin, age, gender, disability, religion, or political belief, etc. If I think I have suffered discrimination, I may contact the state (850) 921-3205 or federal government (404) 562-7886. I understand that Early Learning Coalition services are strictly based on client s eligibility and availability of funds. These services are not an entitlement. At any time if there is any change in funding, sufficient notification will be provided to all individuals receiving Early Learning Coalition services. I have the right to request a fair hearing if found ineligible for a service, if my service is terminated, suspended or reduced, or if I am dissatisfied with any service provided by the Early Learning Coalition of Indian River, Martin, and Okeechobee Counties, Inc. Our administrative office can be contacted at 772-220-1220 or 877-220-1223 for further assistance. I understand that SSN is not required for child care eligibility. My SSN or an assigned ID# will be used to maintain confidentiality, to collect data, and to establish a unique identifier. CONSENTS I understand that developmental screenings and pre/post assessments are administered by Child Care Providers of children who are not enrolled in elementary schools. I give consent to this screening/assessment with the expectation that I will be informed of any recommendations or need for referrals. I agree that necessary information concerning my child may be released to other appropriate agencies. If I am a Martin County resident, I agree that pre/post assessments and demographic information pertaining to my child may be used by the Children s Services Council of Martin County (CSCMC) to evaluate the program s effectiveness. I understand that CSCMC will keep all identifying information provided to it confidential. I give consent for the release of information to the Department of Children and Families and/or the Division of Public Assistance Fraud and/or the local Early Learning Service Provider relating to my eligibility for the receipt of medical benefits and/or payments by the Social Security Administration, and to make inquiry into all statements or information given in the application. By signing, I acknowledge that I have read and agree to all terms, conditions and consents as stated above. Signature Date Page 5 of 5

VERIFICATION OF EMPLOYMENT Date: Dear Employer: is currently receiving, or has applied for subsidized child care. In order to receive or to continue to receive this service, verification of employment is required. Please complete this form and return it as soon as possible or submit a letter with the following information included. PAY SCHEDULE Number of hours worked per week: Number of days worked per week: How often is the employee paid? Daily Weekly Bi-Weekly Semi-Monthly Monthly Rate of pay: Hourly Daily Weekly Other: Is employment season? Yes No If yes, season begins: ends: If employee receives tips, please specify amount? How often? List the gross amounts and dates of checks or cash, which were paid for the last six weeks in the space below. Number of Number of Rate of Pay Period Date Pay GROSS Rate of Regular Hours Overtime Pay for Tips $$ Ending Received Earnings Pay Worked Hours Overtime Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his/her official duty shall be guilty of a felony of the third degree punishable in FS. 414.39 EMPLOYER INFORMATION Company s Name: Address: City/ State: Zip Code: Supervisor s Name: Supervisor s Telephone: ( ) Employer s Authorized Signature: Title: Date: Upon receipt of this form an ELC representative will contact the employer for verification purposes. AUTHORIZATION FOR RELEASE OF EMPLOYMENT RECORDS I hereby give my permission to you, the custodian of records, to release any and all employment records relative to this request to: Early Learning Coalition of Indian River, Martin & Okeechobee Counties Attn: (Eligibility Specialist) Ph: 772-567-7480 Fax: 772-567-7420 Ph: 772-220-1220 Fax: 772-223-3868 Ph: 863-357-1154 Fax: 863-357-2232 A photocopy of this release form will be valid as an original, even though the said photocopy does not contain an original writing of my signature. Employee: Date of Birth: Signature: Dated Signed: Form Verification of Employment with Release 021712