Fia1100A E Form Pdf – Fill Out and Use This PDF

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.

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 (S) Work Schedule for Child Care (Spanish)

FIA-1100a Employer’s Verification

End Time:

Total Weekly

End Time:

Total Weekly

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

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