FIA-1100a (E) Form PDF Details

Navigating the complexities of child care assistance within the framework of the Family Independence Administration (FIA) is made clearer with the introduction of the FIA-1100 and FIA-1100A E Pdf forms. These forms serve as essential documents for individuals applying for or receiving child care assistance, ensuring their work schedules are accurately captured and verified. The FIA-1100 form allows applicants to attest to their work schedule, which is pivotal in determining the amount of child care assistance needed. Conversely, the FIA-1100A, known as the Employer’s Verification form, secures an employer’s confirmation of an applicant's work schedule. These forms embody a crucial step for applicants and participants within the child care assistance process, from application and recertification to eligibility reassessments. Offering a detailed approach, the forms aim to streamline the procedure by incorporating work schedule information for other adults in the household if applicable, thus covering a comprehensive range of situations including self-employment and changes in employment status or hours. Furthermore, the policy ensures the provision of accurate, up-to-date information, facilitating a smoother process for all parties involved.

QuestionAnswer
Form NameFIA-1100a (E) Form
Form Length9 pages
Fillable?Yes
Fillable fields203
Avg. time to fill out21 min 27 sec
Other namesfia 1021b form pdf, fia 1100a e 12 27 2016, fia time 1100a online, fia 1100 form pdf

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FAMILY INDEPENDENCE ADMINISTRATION

Matthew Brune, Executive Deputy Commissioner

James K. Whelan, Deputy Commissioner

Stephen Fisher, Assistant Deputy Commissioner

Policy, Procedures, and Training

Office of Procedures

POLICY BULLETIN #13-80-OPE

(This Policy Bulletin Replaces PB # 13-77-OPE)

Date:

Subtopic(s):

September 13, 2013

Child Care

This procedure can Revision to the Original Policy Bulletin:

now be accessed on the

 

FIAweb.

This policy bulletin is being revised to clarify the use of the Work

 

 

Schedule For Child Care (FIA-1100) and the Employer’s Verification

 

(FIA-1100a) forms.

 

Purpose:

 

The purpose of the policy bulletin is to provide staff with information

 

on two child care forms, the Work Schedule For Child Care (FIA-

 

1100) and the Employer’s Verification (FIA-1100a). The FIA-1100 is

 

an attestation of the applicant’s/participant’s work schedule. The

 

FIA-1100a is the employer’s verification of the

 

applicant’s/participant’s work schedule. As required by regulations

 

and social service law, every applicant or participant who is

 

requesting child care assistance must provide his/her work schedule

 

to justify the hours of child care required.

 

The Child Care Return Appointment form (W-273NN) has been

 

revised to include the FIA-1100 and the FIA-1100a in the list of

 

forms to be returned at the child care return appointment.

The FIA-1100 and the

Every applicant/participant requesting child care whose hours of

FIA-1100a does not

employment is not controlled/monitored by the Family Independence

apply to individuals

Administration (FIA) (See list below) must complete and submit the

assigned to full-time

FIA-1100 in order to receive or continue receiving child care

WEP and B2W.

 

payments.

HAVE QUESTIONS ABOUT THIS PROCEDURE?

Call 718-557-1313 then press 3 at the prompt followed by 1 or send an e-mail to FIA Call Center Fax or fax to: (917) 639-0298

Distribution: X

If the FIA-1100 has been completed, the child care information can be entered into ACCIS if all of the appropriate provider forms are complete and approved by the enrollment agency, if required.

PB #13-80-OPE

The following individuals are required to complete an FIA-1100:

Individuals who are:

∙applying for Cash Assistance (CA) who report employment income.

∙receiving CA and report new employment income.

∙employed and report a permanent change in:

work hours (increase or decrease).

employment status (part time to full time or vice versa).

∙applying for or in receipt of Child Care in Lieu of Cash Assistance (CILOCA).

∙employed as a child care provider even if they are receiving payments through the Automated Child Care Information System (ACCIS).

Note: Individuals who provide a letter from the employer on the employer’s stationary with contact information that includes the

daily work schedule (i.e., M – F 9am – 5pm) are not required to complete the FIA-1100 or to have the employer complete the FIA-1100a.

The FIA-1100 and the FIA-1100a must be used at application and recertification and will be incorporated into the six month eligibility mailer process at a later date.

At the interview, the JOS/Worker must print the FIA-1100 and the

FIA-1100a. The applicant/participant must complete the FIA-1100 on the same day of the interview. If the applicant’s/participant’s work

schedule varies, he/she must enter the schedule most commonly worked. If there is a second employed parent or guardian of the child, his/her work schedule must also be captured on the same form in the “Work Schedule For Other Adults in Household” section. If the second employed parent or guardian is not present at the interview, the parent or guardian that is present must enter the information for that individual in the second part of the FIA-1100. The applicant/participant requesting child care must attest to both work schedules.

If the applicant/participant has a second employment, the Work Schedule For Other Adults in Household section on the FIA-1100 must be used to enter the hours for the second employment.

FIA Policy, Procedures, and Training

2

Office of Procedures

PB #13-80-OPE

Individuals who are self- employed are not required to complete the FIA-1100a.

Please use Print on

Demand to obtain copies of forms.

If for any reason the applicant/participant cannot fill out the FIA-1100 while present at the interview (example: Applicant/participant is not sure what their permanent schedule will be because he/she just started working and is now in a training schedule.), the FIA-1100 can be completed and submitted at the child care return appointment. The JOS/Worker must ensure that the FIA-1100 is checked on the W-273NN.

Once the FIA-1100 is completed by the applicant/participant, it must be scanned and indexed into the POS case record. Child care cannot be authorized until the FIA-1100 is completed, signed and submitted.

The FIA-1100a must be given to the applicant/participant to take to the employer. One FIA-1100a must be given for each employer and for each parent/guardian. The JOS/Worker must make a five day child care return appointment in New York City Work Accountability and You (NYCWAY), check the FIA-1100a box on the W-273NN and give the form to the applicant/participant to return with the completed FIA-1100a and other child care provider forms, if required.

When the applicant/participant returns with the FIA-1100a completed by the employer, it must be scanned and indexed into the POS case record.

At the return appointment if the applicant/participant wishes to change the work schedule previously reported, a new FIA-1100 must be completed.

If the applicant/participant fails to return the FIA-1100a, the JOS/Worker must mail an FIA-1100a to the employer and enclose a business reply envelope. If the FIA-1100a is not returned, and the completed FIA-1100 is filed in the record, no adverse action will be taken.

Effective Immediately

Related Item:

PD #13-18-EMP

PD #13-19-ELI

Attachments:

FIA-1100

Work Schedule for Child Care

FIA-1100 (S) Work Schedule for Child Care (Spanish)

FIA-1100a Employer’s Verification

FIA Policy, Procedures, and Training

3

Office of Procedures

 

PB #13-80-OPE

W-273NN

Child Care Return Appointment (Rev. 8/20/13)

W-273NN (S)

Child Care Return Appointment (Spanish)(Rev.

 

8/20/13)

FIA Policy, Procedures, and Training

4

Office of Procedures

FIA-1100 (E) 8/20/2013

LLF

Work Schedule For Child Care

If you wish to receive or already receive subsidized child care, in order to properly account for your child care needs, please complete this form with information about your employer and your work schedule. If your work schedule changes often, please provide your most commonly worked schedule. You must complete this form to receive child care.

Applicant/Participant's Name:

Cash Assistance Case Number:

Employer's Name:

Employer's Address:

Weekly Schedule

Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Start Time:

End Time:

Total Weekly

hours worked:

Number of hours worked:

Total Weekly Travel Time: If your travel time varies each day, use your longest travel time and multiply by five (5).

For example: Two (2) days a week your travel time is two (2) hours, and three (3) days a week your travel time is one (1) hour, your total travel time should be 5x2 = 10 Hours.

Total Weekly Travel Time:

Work Schedule For Other Adults in Household

Relationship to Child:

Parent

Guardian

Applicant/Participant's Name:

Cash Assistance Case Number:

Employer's Name:

Employer's Address:

Weekly Schedule

Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Start Time:

End Time:

Total Weekly

hours worked:

Number of hours worked:

Total Weekly Travel Time: If your travel time varies each day, use your longest travel time and multiply by five (5).

For example: Two (2) days a week your travel time is two (2) hours, and three (3) days a week your travel time is one (1) hour, your total travel time should be 5x2 = 10 Hours.

Total Weekly Travel Time:

I swear or affirm that the Information on this form is true and correct.

Applicant/Participant’s Signature: ___________________________________________ Date: ____________________

FIA-1100 (S) 8/20/2013

LLF

Horario de Trabajo para Cuidado Infantil

Si usted desea recibir o ya está recibiendo cuidado infantil subvencionado, a fin de rendir cuenta de sus necesidades de cuidado infantil, favor de llenar este formulario con información sobre su empleador y su horario de trabajo. Si su horario de trabajo cambia a menudo, favor de proporcionar su horario más comúnmente trabajado. Usted debe llenar este formulario para recibir cuidado infantil.

Nombre del Solicitante/Participante:

Núm. del Caso de Asistencia en Efectivo:

Nombre del Empleador:

Dirección del Empleador:

Horario Semanal

Días

lunes

martes

miércoles

jueves

viernes

sábado

domingo

Hora de comienzo:

Total de Horas

Hora final:Trabajadas Semanales:

Número de

horas trabajadas:

Total del tiempo de viaje semanal: Si su tiempo de viaje varía cada día, use su tiempo de viaje más largo y multiplique por cinco (5). Por ejemplo: Dos (2) días a la semana usted viaja dos (2) horas, y tres (3) días a la semana, viaja una (1) hora, el total de su tiempo de viaje debe ser 5x2 = 10 Horas.

Total del Tiempo de Viaje:

Horario de Trabajo de Otros Adultos en el Hogar

Relación con el Niño:

Padre/madre

Tutor

Nombre del Solicitante/Participante:

Núm. del Caso de Asistencia en Efectivo:

Nombre del Empleador:

Dirección del Empleador:

Horario Semanal

Días

lunes

martes

miércoles

jueves

viernes

sábado

domingo

Hora de comienzo:

Total de Horas

Hora final:Trabajadas Semanales:

Número de horas trabajadas:

Total del tiempo de viaje semanal: Si su tiempo de viaje varía cada día, use su tiempo de viaje más largo y multiplique por cinco (5). Por ejemplo: Dos (2) días a la semana usted viaja dos (2) horas, y tres (3) días a la semana, viaja una (1) hora, el total de su tiempo de viaje debe ser 5x2 = 10 Horas.

Total del Tiempo de Viaje:

Juro y afirmo que la información en este formulario es verídica y correcta.

Firma del Solicitante Participante:____________________________________________ Fecha: ________________

FIA-1100a (E) 08/20/2013

Employer’s Verification

Employee’s Name:

In order to receive New York City Child Care, your employee listed above must provide this agency with a work schedule verified by his/her employer. Please complete your employee’s work schedule in the spaces below. If your employee works a variable schedule, please fill in his/her most commonly worked schedule.

Work Schedule For Child Care

Employer’s Name:

Employer’s Address:

 

 

 

 

 

 

 

City:

State:

 

Zip Code:

 

 

 

 

Weekly Schedule

 

 

 

 

Days

Monday

Tuesday Wednesday

Thursday

Friday

Saturday

Sunday

 

Start Time:

 

 

 

 

 

 

 

End Time:

 

 

 

 

 

 

Total Weekly

 

 

 

 

 

 

Hours Worked

 

 

 

 

 

 

 

Number of

 

 

 

 

 

 

 

hours worked:

 

 

 

 

 

 

 

The above schedule is (please check one):

 

 

 

 

 

 

Standard

Variable

 

 

 

 

 

Employer or Employer Designee’s Signature: _______

________________________ Date: ___________________

Title:

 

 

 

 

Phone number:

_______

Form W-273NN LLF

Rev. 8/20/13

Date:

Case Number:

Case Name:

Job Center:

Child Care Return Appointment

Please return for the following reason(s)

I. CHILD CARE IS NEEDED

133S (Participant/Sanctioned Individual)

933S (Applicant)

Documents required:

II.ADDITIONAL INFORMATION IS NEEDED 133D (Participant/Sanctioned Individual)

Check the boxes that apply

Complete and return the child care provider enrollment form(s) provided Secure and return all documentation listed

933D (Applicant)

Check the boxes that apply LDSS-4699

LDSS-4700

CS-274W

Documents required:

FIA-1100

 

FIA-1100a

I will bring the above-mentioned documentation with me to my new appointment.

I will return to this mandatory engagement appointment on:

Appointment Date:

 

Time:

Telephone:

Address:

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip:

 

This is a mandatory engagement appointment. Failure to keep this appointment may result in a reduction in your Cash Assistance and/or SNAP benefits. Please call the telephone number above if you need to reschedule this appointment.

You must report to the Job Center with this form.

Applicant's/Participant's/Sanctioned Individual's Signature

Date

Form W-273NN (S) LLF

Rev. 8/20/13

Fecha:

Número del Caso:

Nombre del Caso:

Centro de Trabajo:

Cita de Vuelta de Cuidado Infantil

Favor de regresar por la(s) siguiente(s) razón(es)

I. SE NECESITA CUIDADO INFANTIL

133S (Participante/Persona Sancionado[a])

933S (Solicitante)

Documentos necesarios:

II. SE NECESITA INFORMACIÓN ADICIONAL

133D (Participante/Persona Sancionado[a])

Marque las casillas que correspondan

Llene y devuelva el formulario(s) de inscripción del proveedor de cuidado infantil

Consiga y devuelva toda la documentación listada

Documentos necesarios:

933D (Solicitante)

Marque las casillas que correspondan LDSS-4699

LDSS-4700

CS-274W

FIA-1100

FIA-1100a

Traeré toda la documentación mencionada más arriba a mi nueva cita.

Regresaré a esta cita de participación obligatoria el:

Fecha de la Cita:

 

 

Hora:

 

 

Teléfono:

Dirección:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ciudad:

 

Estado:

 

 

Código Postal:

 

Ésta es una cita de participación obligatoria. El no cumplir con esta cita puede resultar en una reducción de sus beneficios de Asistencia en Efectivo y/o SNAP. Favor de llamar al número de teléfono más arriba si necesita reprogramar esta cita.

Usted tiene que presentarse al Centro de Trabajo con este formulario.

Firma del Solicitante/Participante/Persona Sancionado(a)

Fecha

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