Form Dco 97 – Fill Out and Use This PDF

HOUSEHOLD INCOME Proof of all income must be provided.

RIGHTS AND RESPONSIBILITIES Read carefully and sign at the bottom.

1.You have the right to a decision on your application within seven (7) calendar days after all necessary information is submitted.

2.You cannot be denied child care assistance on the basis of race, color, sex, age, disability, religion, national origin, politica belief or failure to disclose a Social Security Number.

3.You may choose any child care provider that meets the requirements of DHHS and the Child Care Assistance Program.

4.Information you provide will not be released without your written consent, except to parties allowed by law. Your name and Social Security Number may be furnished to employers, government agencies, educational institutions or any other party deemed necessary by DHHS to determine your eligibility.

5.If any adverse action is taken on your application or child care case, you have the right to an Internal Review. You may appeal any review decision by sending a written request to: Arkansas Department of Health and Human Services, Office of Appeals and Hearings, P.O. Box 1437, Slot N-401, Little Rock, AR 72203.

6.You must help establish your eligibility by FULLY completing this application and providing as much information as possible about your circumstances. Providing false information or withholding information may result in criminal prosecution.

7.You must report ALL changes that affect eligibility to your Child Care Eligibility Specialist within ten (10) days of the change. These changes include but are not limited to: Address or Telephone, Household Members, Employment, Child Support, Child Care Needs, Training/Education or Monthly Income Changes of Greater than $100. Failure to report changes may result in your case being closed and a referral to the Fraud Unit. You are responsible for any overpayments resulting from changes in your status.

8.You understand that DHHS will not retroactively pay or reimburse you for child care expenses. The first day that DHHS will pay for child care is the day DHHS determines eligibility requirements have been met and you are approved for services.

9.Within six months of receiving child care benefits, you must submit documentation that you are receiving child support or have applied to pursue child support from the absent parent(s) of children for whom assistance is needed.

10.You agree to cooperate in any DHHS investigation concerning your case. You understand that failure to cooperate will result in termination of assistance.

11.If you wish to change child care providers, you must give a minimum of one (1) week’s written notice to your Child Care Specialist. If such notice is not given, you will be responsible for any payments to the new child care provider until the Child Care Specialist officially completes the change.

12.Social Security Numbers shall be used for identification purposes only and are not required for eligibility.

STUDENTS ONLY: Students enrolled in education or training programs must maintain full-time status to retain eligibility. Students are allowed a maximum of five (5) years to complete education. Grade reports are checked each term to verify completion of courses. If you reduce your hours, you MUST report this to your Child Care Eligibility Specialist within ten (10) days, and you will be required to obtain work of up to 30 hours per week to remain eligible for assistance. Grades are checked at the end of every full term in which you receive assistance. You must maintain a “C” average (2.00 GPA) in order to continue receiving assistance. If you drop below a 2.00 average, you will be placed on academic probation for one (1) term. If your grades do not meet this requirement the following semester, you will become ineligible for assistance and your case will be closed unless full-time employment is obtained within 30 days..

CERTIFICATION: I certify that I have read and understand my Rights and Responsibilities. I authorize DHHS to collect information from other sources to determine my eligibility for assistance. I authorize any source DHHS deems necessary to determine eligibility to release information concerning me. I certify under penalty of perjury and fraud that all information I have supplied is true and correct. I understand that giving false information or withholding information may result in criminal prosecution and the repayment of financial assistance made on my behalf.

Signature		Print Name
		Date

DCC-513 Page 2 of 2 (7/1/07)

Arkansas Department of Human Services

Verification of Earnings

TO EMPLOYER:

To determine eligibility and correct benefits for your employee we need the information requested below. This will enable us to ensure that the public funds are used only for the actual and correct benefits to which a household is entitled. PLEASE COMPLETE THE ITEMS CIRCLED AS WELL AS THE SIGNATURE SECTION AT THE BOTTOM OF THIS FORM.

If you need this material in a different format such as large print, contact your local DHS county office. Address Department of Human Services

Caseworker

	Telephone Number		TDD#
	Employee					Casehead
	SSN of Employee					Case Number

1.The above employee began work __________ and earns $_________ per hour. He/she works an average of

_______ hours per week. Date first pay to be received _________.

Anticipated gross amount of 1st pay $_________.
Employee is paid:	Weekly	Monthly	Other -- Please indicate how often _______________
	Every 2 weeks		Twice Monthly

2.Please show GROSS EARNINGS (before any deductions) PAID TO this employee as indicated. Please list each pay check separately including vacation pay and bonuses.

Pay Period	Date	Hours			Housing/Utilities
Ending	Received	Worked	Gross Wages	Tips	Paid above wages

REC’D in the Month of

For the past consecutive pay periods

3.Earnings: Are any of the earnings funded by JTPA - On The Job Training Program? Yes or No

4.Termination: If employee no longer is employed by you, what was the date and reason for leaving this job?

__________________________________________________________________________________

Date last check will be received __________________ and gross amount _______________________

5.Additional Information/Expected Changes: (such as layoffs, raises, increased or reduced hours, vacation pay, bonuses, and sick pay).

______________________________________________________________________________________________

6.Insurance: If employee has insurance through this job, what is the name and address of the insurance

carrier?_________________________________________________________________________________________

Claims processing address if different than insurance carrier ______________________________________________

Policy Number _______________________________ Effective date of policy ________________________________

Type of coverage __________________________________________________ Policy:

individual or

group

Policyholder and covered individuals _________________________________________________________________

I do hereby certify that the above information is factual and correct to the best of my knowledge.

____________________________________________	_____________________	___________________
Employer/Payroll Clerk Signature	Date	Telephone
____________________________________________	____________________________________________
Place of Business	Address

DCO-97 (R. 2-91)-100970

ARKANSAS DEPARTMENT OF HEALTH AND HUMAN SERVICES

Division of Child Care and Early Childhood Education

Child Care Arrangement Verification

This is NOT an approval for services.

Name of Casehead/Applicant______________________________________________________

The information below must be completed by the CHILD CARE PROVIDER

where children are either currently attending or will be attending.

CHILD CARE PROVIDER: List children of casehead who are enrolled and complete all applicable information for each child. Return form to casehead upon completion.

Start

Head Start/ABC

Type of

Time of

Cost

Child’s Name

Age

Service

Date

Service Requested

Per Day

Requested

 Head Start (Full Day)

Full Day  Night  Weekend

____am ___am

 Head Start (Half Day)

____am ___pm

 Half-Time  Part-Time

$

 ABC

____am ___pm

 Head Start (Full Day)

Full Day  Night  Weekend

____am ___am

 Head Start (Half Day)

____am ___pm

 Half-Time  Part-Time

$

 ABC

____am ___pm

 Head Start (Full Day)

Full Day  Night  Weekend

____am ___am

 Head Start (Half Day)

____am ___pm

 Half-Time  Part-Time

$

 ABC

____am ___pm

 Head Start (Full Day)

Full Day  Night  Weekend

____am ___am

 Head Start (Half Day)

____am ___pm

 Half-Time  Part-Time

$

 ABC

____am ___pm

 Head Start (Full Day)

Full Day  Night  Weekend

____am ___am

 Head Start (Half Day)

____am ___pm

 Half-Time  Part-Time

$

 ABC

____am ___pm

 Head Start (Full Day)

Full Day  Night  Weekend

____am ___am

 Head Start (Half Day)

____am ___pm

 Half-Time  Part-Time

$

 ABC

____am ___pm

*Types of Service:

•Full Day: More than 5 hours per day and up to 10 hours

•Half-Time: 3-5 hours per day, inclusively (Hours do not have to be consecutive.)

•Part-Time: Less than 3 hours per day

•Night: Weekday when more than ½ of total care is after 6:00 p.m.

•Weekend: Care on Saturday and/or Sunday

Signature of Facility Director of Designee		Print Name
Name of Child Care Facility		Telephone Number
Mailing Address	City	Zip Code	County

YES  NO

License No. Quality Approved?

Casehead: Complete and return this form to your Child Care Eligibility Specialist. If you have any questions, please

contact your specialist or the Family Support Unit at 1-800-322-8176 or 501-682-8947.

DCC-552 (7/1/07)