Dhs 4025 Form PDF Details

When navigating the realm of childcare support within Michigan, the DHS 4025 form emerges as a crucial element for families seeking financial assistance. Administered by the Michigan Department of Health and Human Services (MDHHS), this form serves as a gateway for accessing the Child Development and Care (CDC) Program benefits. The form's design comprehensively captures essential details, ranging from provider information to specific child data, ensuring accurate processing and verification for subsidy payments. It is structured to validate the eligibility of both the provider and the children under care, incorporating sections that require attentive completion by both parties involved. Additionally, it embodies the state's commitment to non-discrimination and inclusive support for all families, underlined by its adherence to Public Act 280 of 1939. The mandate for completion and the consequences of non-completion underscore the form's importance in maintaining a transparent and accountable system for childcare support. Moreover, its integral role in the CDC benefits process, from application to approval, illustrates its significance in facilitating essential financial assistance to families, thereby contributing to the broader objective of ensuring accessible, high-quality childcare for Michigan's children.

QuestionAnswer
Form NameDhs 4025 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdhs 4025, dhs cdc provider verification form, child development care provider verification form, mi dhs child

Form Preview Example

Case Name:

Case Number:

Date:

MDHHS Office:

Specialist:

Phone:

Fax:

Specialist ID:

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

AUTHORITY: Public Act 280 of 1939.

COMPLETION: Mandatory.

CONSEQUENCE FOR NONCOMPLETION: Child care subsidy payments will not be authorized.

CHILD DEVELOPMENT AND CARE (CDC) PROVIDER VERIFICATION

PURPOSE: You have received this form because you have applied for assistance with child care expenses through the Child Development and Care (CDC) program or have changed your CDC provider. You must complete and send this form by the Due Date to your MDHHS Specialist via mail, fax or by using www.michigan.gov/mibridges. You will not receive CDC benefits until you complete this form and receive your approval notice.

INSTRUCTIONS:

Work with your chosen provider to complete all the information included on Page 1 and Page 2 of this form. Both you and your provider must read the agreement and sign and date Page 2.

Return the form to your MDHHS specialist by the Due Date. If the form is not received by the Due Date, you or your provider will not receive CDC payments for child care expenses.

You and your provider will receive a notice from the CDC program if care is approved.

 

 

 

 

Due Date:

 

SECTION 1: PROVIDER INFORMATION (To be completed by the provider)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider or Child Care Center Director Name

 

Child Care Center Name

 

 

 

Provider CDC ID #

 

 

 

 

 

 

 

Address (Number and Street)

 

City

 

 

State

Zip Code

 

 

 

 

 

MI

 

County

Telephone Number

Email

 

- -

 

 

 

 

 

 

 

 

 

 

 

 

Do you receive any other payments (such as from an employer, child support, or other assistance program) for caring for the children listed in Section 2?

NO

YES If YES, for what children (list children)?

If YES, whom do you receive payment from?

Where do you usually care for the children listed in Section 2? (Check one)

Note: If you are an unlicensed provider who is not related to the children in Section 2, you must provide care in the children’s home.

Child Care Center

Group Child Care Home

Family Child Care Home

Home Where The Child Lives

My Home

 

SECTION 2: CHILD INFORMATION (To be completed by the provider):

(Please list all children in the family in your care. Attach a list of additional children to this form if needed.)

Child’s Name

Date of

 

Date Care

Is the child related to you?

If YES, how are you related?

Birth

 

Began

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

NO

YES

 

2.

 

 

 

NO

YES

 

3.

 

 

 

NO

YES

 

4.

 

 

 

NO

YES

 

DHS-4025 (Rev. 12-15) Previous edition obsolete.

1

For additional assistance, contact your MDHHS specialist.

Case Name

Case Number

Specialist

SECTION 3: PARENT/SUBSTITUTE PARENT AGREEMENT (To be completed by the parent) By signing, you agree to the following:

1.I understand that if I choose an unlicensed provider:

a.I am responsible for any child care expenses for the time my child is in care before my provider completes the Great Start to Quality Orientation training.

b.CDC payments will be issued to me and I am responsible for paying my provider.

c.I am responsible for reporting child care payments to the IRS and issuing my provider a Form W-2 or Form 1099 MISC, if appropriate.

2.I certify that my child or children are or will be in care with this provider as of the “date care began” listed in Section 2.

3.I understand that my child care agreement is between myself and my provider.

4.I understand that the Department may request information from me in order to verify my provider’s billing information.

5.I understand and agree that if an overpayment is made to my provider for any reason, my provider must repay the extra payments. To help repay the money, the Department may reduce any future payments to my provider by up to 20%.

6.I understand that I may be prosecuted for perjury or fraud if I intentionally leave out or give any false information that causes me to receive CDC benefits that I am either not qualified for, or are greater than what I should receive.

7.I understand if I violate any of the program rules, I may be disqualified from the program for six (6) months, 12 months, or a lifetime.

Parent/Substitute Parent Signature

Date

SECTION 3: PROVIDER AGREEMENT (To be completed by the provider)

By signing, you agree to the following:

1.I understand if I am an unlicensed provider:

a.I must apply to be a CDC provider by completing the CDC Unlicensed Provider Application. The application can be found at www.michigan.gov/childcare

b.I will not receive CDC payment for any care I provide in the period before I complete the Great Start to Quality Orientation training. More information on the training can be found at www.GreatStarttoQuality.org.

c.CDC payments will be issued to the parent of the child or children in care. The parent is responsible for paying me, reporting my wages to the IRS, and issuing me a Form W-2 or Form 1099 MISC, when appropriate.

d.I will use the CDC Daily Time and Attendance form found at http://www.michigan.gov/childcare.

2.I understand that I am not employed by the State of Michigan or the CDC Program, and that I will not receive unemployment insurance.

3.I will maintain time and attendance records for each child in my care. Each child’s parent/substitute parent must sign the records each day they are in my care. I will retain these records for four (4) years.

4.Parents of the children in care will have unlimited access to their children while in my care.

5.If an audit or investigation finds that I do not keep accurate time and attendance records, I may have to return CDC payments to the Department.

6.If I am overpaid for any reason, I must repay the Department, even if I am overpaid in error. If I am overpaid, the Department may hold up to 20% of any future payments.

7.I am responsible for what happens in the CDC I-Billing system by anyone using my PIN.

8.I will immediately contact the CDC Central Reconciliation Unit at 866-990-3227 to request a PIN reset if someone has accessed my PIN without my permission.

9.I will not bill for hours when the child is in school, to hold a spot for a child, or if the child is not expected to return to my care.

10.I understand that I may be prosecuted for perjury or fraud if I intentionally leave out or give false information that causes the parent/substitute parent to receive CDC benefits they are either not qualified for, or are greater than what they should receive.

11.I understand if I violate any of the program rules, I may be disqualified from the program for six (6) months, 12 months, or a lifetime.

Provider Signature

Date

For more information and requirements, see the CDC program handbook at

http://www.michigan.gov/childcare

DHS-4025 (Rev. 12-15) Previous edition obsolete.

2

For additional assistance, contact your MDHHS specialist.

How to Edit Dhs 4025 Form Online for Free

The whole process of filling in the mi cdc provider verification form is actually comparatively quick. Our experts ensured our software is easy to understand and helps complete almost any form in a short time. Below are a couple of steps you will have to follow:

Step 1: Choose the button "Get Form Here" on the following site and hit it.

Step 2: Once you have entered the mi cdc provider verification form editing page you'll be able to find each of the actions you'll be able to undertake regarding your template from the upper menu.

Fill out the next areas to prepare the template:

step 1 to writing child development care provider verification

Write down the appropriate particulars in provider will not receive CDC, You and your provider will, SECTION PROVIDER INFORMATION To, Child Care Center Name, Provider CDC ID, Due Date, Address Number and Street, City, County, Telephone Number, Zip Code, State MI, Email, Do you receive any other payments, and YES part.

part 2 to filling out child development care provider verification

The software will demand you to provide particular important information to effortlessly fill out the field NO NO NO NO, YES YES YES YES, DHS Rev Previous edition obsolete, and For additional assistance contact.

stage 3 to entering details in child development care provider verification

Identify the rights and obligations of the sides within the field Case Name, Case Number, Specialist, SECTION PARENTSUBSTITUTE PARENT, a I am responsible for any child, Orientation training, b CDC payments will be issued to, appropriate, I certify that my child or, help repay the money the, I understand that I may be, receive CDC benefits that I am, I understand if I violate any of, Date, and SECTION PROVIDER AGREEMENT To be.

child development care provider verification Case Name, Case Number, Specialist, SECTION  PARENTSUBSTITUTE PARENT, a I am responsible for any child, Orientation training, b CDC payments will be issued to, appropriate, I certify that my child or, help repay the money the, I understand that I may be, receive CDC benefits that I am, I understand if I violate any of, Date, and SECTION  PROVIDER AGREEMENT To be fields to fill out

Finish by looking at all these fields and preparing them correspondingly: parentsubstitute parent to receive, Date, For more information and, DHS Rev Previous edition obsolete, and For additional assistance contact.

Filling in child development care provider verification part 5

Step 3: Hit the Done button to save your form. Now it is ready for transfer to your gadget.

Step 4: To protect yourself from any type of hassles later on, try to generate as much as a few duplicates of your file.

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