Form Cd 9600 PDF Details

In order to file your Form 9600 with the correct jurisdiction, it is important that you determine which form is appropriate for your specific circumstances. The Form 9600 is used to request an administrative adjustment of tax, and there are three different versions of this form depending on the taxpayer's location and status. By understanding which form to use and how to complete it correctly, you can avoid any delays in processing your request. In this blog post, we will provide an overview of the Form 9600 and explain how to determine which version is appropriate for you. We will also discuss common mistakes taxpayers make when completing this form and offer tips for ensuring accurate submission. Stay tuned for our next blog post, where we will provide more detailed information about each section of the Form 9600!

QuestionAnswer
Form NameForm Cd 9600
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesca cd certification eligibility, cd 9600 application, 9600 child, california cd child services

Form Preview Example

Confidential Application for Child Development Services and Certification of Eligibility

Form CD 9600, Page 1, (REV 08/16)

Agency Name:

Family Identification/Case No.:

Initial Subsidized Service Date:

Type of Application: (Check one) Initial

Recertification

Note: State regulations require a formal application and certification for child development services. You will receive written notice of your eligibility no later than 30 days from the date of your signature on this form. Eligibility is determined on the basis of need for child development services and either CalWORKs status or adjusted gross monthly income in relation to family size. This form must be completed by an agency representative in consultation with the family. Refer to the instructions for the completion of this form.

Section I. Family Identification. If you are a single parent/caretaker, check this box:

See Instructions, Section I.

Name of parent/caretaker (full name, including middle initial)

 

Social Security Number - parent A* (See instructions.)

Gender

Phone no. (home)

Phone no. (work/school)

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of parent/caretaker (full name, including middle initial)

 

Gender

Phone no. (home)

Phone no. (work/school)

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

 

 

 

 

City

State

Zip

FIPS code

 

 

 

 

 

 

 

Section II. Family Eligibility and Reason for Needing Service

 

 

 

 

 

A. Family Eligibility Status (check as many as apply)

 

 

 

 

 

 

Protective

Current Aid

 

Income

Homeless

Programs for the severely handicapped

Services

Recipient

Eligible

 

 

 

 

 

B.Reason for Needing Service. Indicate all the reasons for needing care for each adult listed above. Enter “A” or “B” referring to parent/caretaker listed above. Attach documentation. (This section does not apply to part-day state preschool programs or programs for severely handicapped.)

Parent/

Reason for Needing Service

Parent/

Reason for Needing Service

Parent/

Stages 1, 2, and 3 CalWORKs recipients only

Caretaker

Caretaker

Caretaker

 

 

 

 

 

 

 

 

 

 

 

 

Child protective services

 

Education or training

 

CalWORKS activities

Date parent became

 

 

 

 

 

 

ineligible for aid:

 

Parent/caretaker incapacitated because of medical or

 

Actively seeking employment

 

Diversion

 

 

 

 

 

psychiatric special needs

 

 

Date: ____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Working

 

Seeking permanent housing

Record date of entry into each stage:

 

 

 

Stage 1________ Stage 2________ Stage 3________

 

 

 

 

 

 

 

 

 

 

 

C.Employment/Training Information. Must be completed for each adult listed in Section I above to document need on the basis of employment or training. (Attach documentation)

 

Parent/

 

 

Employer/School

 

 

Street Address

 

City

Zip

 

 

Caretaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Days and working/

From:

 

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

Sun.

 

 

training hours:

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/

 

 

Employer/School

 

 

Street Address

 

City

Zip

 

 

Caretaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Days and working/

From:

 

Mon.

Tues.

Wed.

Thurs.

Fri.

Sat.

Sun.

 

 

training hours:

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section III. Family Adjusted Gross Monthly Income and Size

A. Family monthly income. The family's adjusted monthly income from all sources (Attach verification and documentation.): $_______________

B. Family income sources (Check all that apply. Do not count the gray shaded areas in Section III. A above.) Black shaded boxes for CalWORKs recipients only.

C.Family size (See “Funding Terms and Conditions” for instructions on calculating family size.): __________________

Employment, including self-employment

Child support

Cash or other assistance under Title IV of the Social Security Act (TANF)

State-only alien and two-parent programs for CalWORKs recipients

Other federal cash income programs (such as SSI)

Housing voucher or cash assistance

Assistance under the Food Stamps Act of 1977

Other

Section III B is for federal data collection purposes only and does not need to be completed before the provision of child care services.

Confidential Application for Child Development Services and

Certification of Eligibility

CD 9600 Page 2 (REV. 08/16)

Section IV. Data on Children. List all children residing in the home and counted in the family size.

Complete for all children residing in the home

Complete only for children served by your agency

For children enrolled in more than one program or site, use additional lines as needed

 

(1)

 

(2)

(3)

(4)

(5)

(6)

 

(7)

(8)

 

(9)

 

 

(10)

 

 

 

 

 

Full Name

Gender

Birth Date

Adjustment

 

 

 

Native

 

 

 

 

 

Hours of Care per Day

 

 

 

 

of Child

 

 

 

Factor

 

 

Language

Program

Type of Care

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

Code

Code

 

 

 

 

 

 

 

Including Middle

M

F

 

 

 

 

Is child

 

 

 

 

 

 

 

 

 

Ethnicity

Race

 

 

 

 

 

 

 

 

 

 

 

 

Initial

 

 

MM/DD/YYYY

 

Lan-

limited

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

guage

English

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

Proficient?

 

 

M

T

W

TH

F

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider/site name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider/site name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider/site name:

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider/site name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider/site name:

 

V

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider/site name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

Section V. Certification and Signature of Parent/Caretaker.

 

 

 

 

 

 

 

 

 

 

1. I understand that I am self-certifying single parent status under penalty of perjury in

5. I understand that I must renew my eligibility at least once a year or 3 months for

Section 1 of this document when the single parent/caretaker box has been checked.

at-risk. I further understand that if I do not renew my eligibility, I will no longer be

Parent Initials: _____________

 

 

 

 

 

 

eligible for subsidized child care services for my child.

 

 

 

 

2. I will notify the agency within 5 calendar days of any change in my family income,

6. I understand that I will receive a notice of approval or disapproval of my

 

 

family size, or reason for needing child development services.

 

 

 

application within 30 days from the date I sign this form.

 

 

 

 

3. I understand that the information about my eligibility may be reviewed by

 

7. I understand that this certification is not complete until all documentation is

 

representatives of the State of California, the federal government, independent

submitted and this form has been reviewed, signed, and dated by an agency

 

auditors, or others as necessary for the administration of the program.

 

representative and signed and dated by me.

 

 

 

 

 

 

4. I understand that if the agency denies this application for services, I have the right to

8. I certify that my family assets do not exceed $1,000,000; Child Care and

 

 

appeal.

 

 

 

 

 

 

 

 

 

Development Block Grant Act Section 658 P (4)(B).

 

 

 

 

I declare under penalty of perjury that the above information is true and correct to the best of my knowledge.

 

 

 

 

 

 

 

Signature

A

 

 

 

Date

 

 

 

 

 

Relationship to Child:

Parent

Grandparent

Guardian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foster Parent

Other: Please describe _________________

 

 

 

Signature

B

 

 

 

Date

 

 

 

 

 

Relationship to Child:

Parent

Grandparent

Guardian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foster Parent

Other: Please describe _________________

 

 

 

Section VI. Family Fee (Refer to fee schedule.).

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Fee

 

 

 

 

Flat Monthly Fee Rate (See the instructions for Section VI.)

 

 

 

 

 

 

Full-time

Flat Monthly Rate:

 

Specifics:

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part-time

Flat Monthly Rate:

 

Specifics:

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section VII. For Office Use Only. (Certification is not complete until eligibility is reviewed, signed, and dated by an agency representative.)

 

 

 

 

 

 

 

 

 

 

Date Notice of Action Sent

Date Notice of Action Given

 

First date of subsidized

Last date of

 

 

Eligibility Status

Accepted

Denied

(Attach copy)

 

 

 

(Attach copy)

 

 

service

 

 

enrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Authorized Agency Representative

 

 

 

 

 

Title

 

 

Telephone number

Date

 

 

 

Signature of Supervisor (Optional)

 

 

 

 

 

 

Title

 

 

Telephone number

Date

 

 

 

CD 9600 (Rev. 08/16)

Instructions Page 1

Instructions for Completing Form CD 9600:

Confidential Application for Child Development Services and Certification of Eligibility

Form CD 9600 (or documentation containing the same information) must be completed and signed by the parent and an agency representative before the child enters the child development program. Families must notify the agency within 5 calendar days of any change in my family income, family size, or reason for needing child development services. If such changes occur, agency staff must update the certification. Notification of changes are not required for part-day state preschool or severely handicapped programs. All certification forms and documentation must be maintained in the family file.

Social Security Number (SSN) Collection Consent

Form CD 9600A, the Child Care Data Collection/Privacy Notice and Consent Form, must be completed and signed by all heads of households in all CDE- funded programs. If the head of household gives consent to use their SSN, the SSN should be inserted on the CD 9600. If the head of household does not give consent, leave the SSN space blank on the CD 9600. In "family of one" situations the SSN will not be collected; therefore, completion of the CD 9600A is not required. When completed, attach the CD 9600A to the CD 9600.

*The social security number is to be listed only for heads of households who have given consent on form CD 9600A. In all cases, a CD 9600A must be completed and signed by the head of household and attached to the CD 9600. In "family of one" situations, no SSN is required and no CD 9600A will be completed.

Agency Name: Insert the name of the agency providing or funding child care services in this space.

Family Identification/Case Number: This is an optional field and can be used if the agency assigns an identification or case number to each family.

Initial Subsidized Service Date: This is the earliest month and year that the child(ren), as listed on this CD 9600, first started receiving subsidized child care services from your agency. Every CD 9600 must have a month and year entered in this field. This information is for data reporting purposes. If there is a break of three months or more, enter the month child care resumed. If there is a break of less than three months (vacation, for example), enter the original date assistance began, not the date it resumed.

Type of Application: Check the box after "Initial" if this is the first application taken by the agency named on this CD 9600. Check the box after "Recertification" if this is the second or later application taken by the agency listed on this CD 9600.

Section I. Family Identification

Note: If family size includes more than two adults, complete Sections I, II, and III of a second CD 9600 and attach it to the complete CD 9600. You may also use a second CD 9600 to record additional employers or training institutions for the parents listed under A and B in Section I.

If the child lives with only one parent/caretaker who is legally/financially responsible for the child, check the box on the line next to Section I.

A.Information on parent/caretaker A. For the first adult living in the same household as the child(ren), complete all items in Section I, including address information. For the purposes of these instructions

and the certification of eligibility, a parent/caretaker shall be a person who has responsibility for the child. Thus, “parent/caretaker” could refer, for example, to a biological parent, a stepparent, a grandparent, a foster or adoptive parent, or a legal guardian. For SSN information, see above.

FIPS Code. See the “FIPS Codes” section on page three of these instructions to determine the FIPS Code that identifies the state and county where the parent/caretaker lives.

B. Information on parent/caretaker B. If a second parent/caretaker lives in the same household as the child and is included in the calculation of family size, complete all items in Section I B.

Section II. Family Eligibility and Reason for Needing Service

A.Family eligibility status. Check all eligibility categories for which the family qualifies.

B.Reason for needing service. For each parent/caretaker or other adult included in the family size, note with an “A” or “B” all of the reasons for needing services and attach the appropriate documentation. Identify the main reason for needing service with an asterisk if there is more than one reason. Do not complete this section for part-day state preschool or severally handicapped.

CalWORKs recipients only: This box is to be completed for all CalWORKs recipients receiving services in Stages I, 2, or 3.

If a parent/caretaker is completing CalWORKs activities, enter “A” and/or “B” in the box labeled “CalWORKs Activities."

If a parent/caretaker has received a diversion payment, enter “A” and/or “B” in the box labeled “Diversion.”

In the box labeled “Record date of entry into each stage,” enter the initial date of entry into each stage.

For Stage I or II families no longer eligible for CalWORKs aid,

enter the date the parent became ineligible for aid in the box labeled “Date parent became ineligible for aid.”

C.Employment/training information. For each parent/caretaker, enter the name and address of the employer or the institution of training or education, as appropriate. Do not complete this section for part-day state preschool or programs for severally handicapped.

Days and working/training hours. Note the beginning and ending hours for each day that the parent is employed or in a training program.

Section III. Family Adjusted Gross Monthly Income and Size

A.Family monthly income. Enter the family’s total adjusted gross monthly income from all sources. All income must be verified.

B.Family income sources. Check each box to identify all sources of family income. These include sources of income that are not counted for eligibility determinations.

The black shaded boxes are to be completed for CalWORKs recipients only. County welfare departments will identify whether a CalWORKs recipient is receiving CalWORKs benefits under the State-only alien program or the state-only two-parent program. These two programs count toward Temporary Assistance to Needy Families Maintenance of Effort.

The gray shaded boxes are not to be counted in the family’s total adjusted monthly income.

CD 9600 (Rev. 08/16)

Instructions Page 2

Instructions for Completing Form CD 9600:

Confidential Application for Child Development Services and Certification of Eligibility

Section III. Family Adjusted Gross Monthly Income and Size (Continued)

Section III B is for federal data collection purposes and does not need to be completed before the provision of child care services.

C.Family Size. Enter the total family size, including (1) all parent(s)/caretaker(s) listed on the CD 9600; (2) all children named in Section V; (3) any adult listed on a second CD 9600; and (4) any children listed on a second CD 9600.

Section IV. Data on Children

Note: Complete columns 1 and 3 of this section for all children eighteen and under residing in the household. If needed, use a second CD 9600 to record more children.

1.Name of child. List all children residing in the in the household, eighteen and under, related by blood, marriage, or adoption to the parent(s)/caretaker(s) of the child(ren) being served.

2.Gender. Check the appropriate box in column 2 for each child receiving care through this certification.

3.Birth date. In column 3 enter the birth dates of all children listed in column 1 following this format: month/day/year.

4.Adjustment factor code. See the “Adjustment Factor Codes” section in these instructions to determine the adjustment factor code that should be entered in column 4. If no adjustment factor is used, leave this box blank.

5.Ethnicity. Enter a “Y” if the child is Hispanic or Latino. Otherwise, enter an “N”.

6.Race: See the “Race Codes” section in these instructions to determine the race code(s) that should be entered in column 6. At least one code must be entered, but you may enter all codes that apply for each child.

7.Native language. See the “Native Language Codes” section in these instructions to determine the native language code that should be entered in column 7. Use only those native language codes provided. Report the child's primary language. Indicate whether or not the child is limited English proficient with a check mark in column 7. This column must be completed if you claim LEP reimbursement for this child.

8.Program code. See the “Program Codes” section in these instructions to determine the program code(s) that should be entered in column 8. Enter one code per line for each child receiving child care services through this certification. If the child(ren) is enrolled in more than one program or with more than one provider, use additional lines to record this information in columns 8 and 9 for each child.

9.Type of care and relationship to child. See the “Type of Care Codes” section in these instructions to determine the type of care code(s) that should be entered in column 9. Enter the provider or site name in the space provided.

10.Hours of care per day. Enter the amount of child

development services needed each day in column 9. Use the upper line (marked “S”) to indicate the amount of care needed during the school session; use the lower line (marked “V”) to

indicate the amount of time needed during vacations. For preschool-age children, use only the upper line to record the amount of care needed.

Section V. Certification and Signature of Parent/Caretaker

Read and explain the conditions of eligibility and need to the parent/caretaker and make sure he or she understands them before signing the application. Parents must initial item 1 of Section V if self- certifying by checking the box in Section I. Before the agency representative signs the form, the parent/caretaker completing the application must sign and date the form and indicate his or her relationship to the child. At least one signature is required on the application, two parent signatures are optional.

Section VI. Family Fee

Monthly Flat Rate.-Use the most current effective Family Fee Schedule issued by the Early Education and Support Division. Assess the Family Fee according to the family size, total countable income, and number of hours for the child(ren) in the program with the longest hours.

Full-time Fee: Assess a Full-time fee for certified need of 130 hours or more per month.

Part-time Fee: Assess a Part-time fee for certified need of less than 130 hour per month.

If applicable, the field labeled “specifics” should be used to explain determination of fee.

Section VII. For Office Use Only

The agency representative must complete the items in this section. The certification is not complete until it is signed and dated by the agency representative.

The “Signature of Supervisor” is an optional field and is not required.

Completing the Form

Follow these procedures once you have completed the family’s certification:

A.File the completed form in the family file.

B.If the family has a new or updated certification, add it to the family file. Do not remove the earlier applications.

CD 9600 (Rev. 08/16)

Instructions Page 3

Instructions for Completing Form CD 9600:

Confidential Application for Child Development Services and Certification of Eligibility

Section I. Family Identification

Federal Information Processing Standards (FIPS) Codes

The FIPS code consists of a state code, which is a two-digit number, and a county code, which is a three-digit number. The codes are California - 06, Arizona - 04, Nevada - 32 and Oregon - 41.

California County Codes are as follows:

001

Alameda

041

Marin

081

San Mateo

003

Alpine

043

Mariposa

083

Santa Barbara

005

Amador

045

Mendocino

085

Santa Clara

007

Butte

047

Merced

087

Santa Cruz

009

Calaveras

049

Modoc

089

Shasta

011

Colusa

051

Mono

091

Sierra

013

Contra Costa

053

Monterey

093

Siskiyou

015

Del Norte

055

Napa

095

Solano

017

El Dorado

057

Nevada

097

Sonoma

019

Fresno

059

Orange

099

Stanislaus

021

Glenn

061

Placer

101

Sutter

023

Humboldt

063

Plumas

103

Tehama

025

Imperial

065

Riverside

105

Trinity

027

Inyo

067

Sacramento

107

Tulare

029

Kern

069

San Benito

109

Tuolumne

031

Kings

071

San Bernardino

111

Ventura

033

Lake

073

San Diego

113

Yolo

035

Lassen

075

San Francisco

115

Yuba

037

Los Angeles

077

San Joaquin

 

 

039

Madera

079

San Luis Obispo

 

 

If the family resides outside California, list the state code only.

Section IV. Data on Children

Column 4: Adjustment Factor Codes

21

Infant

24

Severely disabled

22

Exceptional needs

25

Limited English proficient (LEP)

23

Child protective services

27

Toddler

Column 6: Race Codes

 

 

 

1

American Indian or Alaskan Native

2

Asian

3

Black or African American

 

4

Native Hawaiian or other

5

Caucasian

 

 

Pacific Islander

Column 7: Native Language Codes

 

 

11

Arabic

24

Hungarian

06

Portuguese

12

Armenian

25

Ilocano

28

Punjabi

42

Assyrian

26

Indonesian

29

Russian

13

Burmese

27

Italian

45

Rumanian

03

Cantonese

08

Japanese

30

Samoan

36

Cebuano

09

Khmer

31

Serbian

 

(Visayan)

 

(Cambodian)

52

Serbo-Croatian

54

Chaldean

50

Khmu

01

Spanish

20

Chamarro

04

Korean

46

Taiwanese

 

(Guamanian)

51

Kurdish

32

Thai

Column 7 Native Language Codes (Continued)

 

39

Chaozhou

47

Lahu

53

Toishanese

14

Croatian

07

Mandarin

33

Turkish

15

Dutch

 

(Putonghua)

38

Ukrainian

00

English

48

Marshallese

35

Urdu

16

Farsi (Persian)

44

Mien

02

Vietnamese

17

French

49

Mixteco

55

Other

18

German

88

Native American

 

Languages

19

Greek

 

Languages

 

of China

43

Gujarati

40

Pashto

66

Other

21

Hebrew

05

Pilipino

 

Languages of

22

Hindi

 

(Tagalog)

 

the Philippines

23

Hmong

41

Polish

99

Other non-

 

English

 

 

 

 

Column 8: Program Codes (Contract Prefix)

For current contract program codes and contract prefixes, access the Child Care and Development Contract Program Types Web page at

http://www.cde.ca.gov/sp/cd/ci/ccdprogramtypes.asp.

Column 9: Type of Care Codes

02 Licensed family child care home

03 Licensed large family child care home

04 Licensed center-based care

05License-exempt in-home (child’s) care provided by a relative

06License-exempt in-home (child’s) care provided by a nonrelative

07License-exempt care provided outside child’s home by a relative

08License-exempt care provided outside child’s home by a nonrelative

11License-exempt center-based care

California Department of Education

August 2016

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