Cs 274W Form – Fill Out and Use This PDF

CS-274W (FACE)

REV. 4/08

Child Care Provider Enrollment Supplement*

To be used with LDSS-4699/LDSS-4700 for all unregulated providers

ADDRESS:

ADDRESS WHERE CARE IS GIVEN:

PROVIDER'S ADDRESS (IF DIFFERENT):

¹The parent/caretaker may, but does not have to, list his/her Social Security number.You cannot be required to disclose your Social Security number as a condition of eligibility for child care services. If provided, your Social Security number will be used to assist in identifying your child care file. It may also be used by Federal, State and local agencies to prevent duplication of services and fraud, and for Federal reporting.

2Legally-responsible relatives (parents, stepparents, and legal guardians) cannot be paid as child care providers for their own child(ren).

3If the provider is less than 18 years old, the Employment of Minors Form must be completed.

Provider/Agency Name: ___________________________________________________________________

ACCIS Provider Number (if available): _______________________________________________________

Provider's License Type: _________________________ License Number: _________________________

Expiration Date: ________ / ________ / ________

Provider Rate (All providers, except ACS-contracted programs, must complete this section.) My weekly child care rates are as follows:

*ATTENTION: 1. Regulated/licensed providers are not required to complete the LDSS-4699 or the LDSS-4700. They should complete only pages 1 and 2 of this form and return to the parent/legal guardian. Regulated providers without an ACCIS number must also submit a copy of their license along with the competed CS-274W.

2.Informal providers must provide documentation of BOTH their identification and their address in order to be paid by ACS. Please ask your JOS/ACS Worker for the Proof of ID and Residency for Your Child Care Provider or "Babysitter" (CS-574FF), which is the list of approved types of ID.

CS-274W (REVERSE)

REV. 4/08

Indicate the weekly schedule(s) of child care services for the child(ren) listed below:

I acknowledge that receiving payment from the City of New York for child care services provided does not make me an employee of the City of New York. I am an employee of the parent/legal guardian of the child for whom I provide care.

Provider Certification

I am enrolling this child in a child care program. I understand that I will be paid only after the child's attendance data is received by ACS and for so long as the above parent/guardian is engaged in an FIA-approved activity or employed. If the parent/guardian fails to meet these criteria, I will be sent a letter from ACS informing me that ACS will no longer pay for child care. I agree that the amount I am charging this parent is not more than the amount I charge for other children of the same age. I understand that I cannot be paid if I do not list all my rates.

I will allow the parent/guardian of the children named on this form unlimited access to his/her children and the premises and will make myself available whenever the children are in my care.

I certify that the statements above are accurate and true to the best of my knowledge. I understand that providing false information may lead to the suspension or termination of payments and the recovery of any payments to which I was not entitled.

Provider's Name (print clearly): ____________________________________ Official Title (if applicable): _________________

Signature: ________________________________________________________________________ Date: _________________

Parent/Guardian Certification

I certify that I have reviewed the above information and that it is correct. I understand I must report any changes to ACS.

Parent/Guardian's Name: ___________________________________________________________________________________

Parent/Guardian's Signature: _________________________________________________________ Date: _______________

For Agency Use Only:

Is child care authorized for this applicant/participant? Yes No

Agency-approved start date for child care: ________ / ________ / ________

MM DD YYYY