Form Dshs 14 417 – Fill Out and Use This PDF

The DSHS 14-417 form is an application used by the State of Washington Department of Social and Health Services for parents or guardians applying for Child Care Subsidy Programs (CCSP). It serves as a comprehensive document to collect information on the applicant's household income, employment details, and childcare provider qualifications to determine eligibility for childcare subsidies. For those in need of financial assistance for childcare, accurately completing the DSHS 14-417 form is a critical step. Click the button below to learn more about how to fill out this form effectively.

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Form Dshs 14 417 PDF Details

The DSHS 14-417 form, issued by the State of Washington Department of Social and Health Services, serves as a critical access point for families seeking child care subsidies under the Child Care Subsidy Programs (CCSP). This comprehensive application dossier compiles pivotal data ensuring the state's ability to evaluate eligibility for subsidies. Applicants are obliged to detail not only personal information but also extensive insights into their household's financial landscape, including employment details and income proofs for the preceding three months, unless income derives from state cash assistance such as TANF, which is exempted. Moreover, the document addresses stipulations for those newly employed lacking pay stubs, incorporating a procedure for subsequent submission. Critical also is the inclusion of information regarding court-ordered child support. Specific pathways are delineated for Working Connections Child Care applicants utilizing Family, Friends, and Neighbors (FFN) as providers, necessitating further documentation to affirm the provider's eligibility, such as identification, legal work status in the U.S., and background checks. Additionally, Seasonal Child Care applicants face geographic and employment criteria, underscoring the form's nuanced approach to assistance eligibility. The necessity for applicants to itemize children’s living arrangements, school, and childcare schedules, alongside an acknowledgment of rights and obligations under penalty of perjury, encapsulates the form’s exacting but essential role in facilitating childcare support for Washington's diverse families.

Question	Answer
Form Name	Form Dshs 14 417
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	dshs child care application forms, 2013, dshs child care, BIRTHDATE

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STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES

CHILD CARE SUBSIDY PROGRAMS (CCSP)

CCSP Application

Date:

PARENT/GUARDIAN

CASE NUMBER

_____

FOLD

Dear Applicant:

We are sending this application because you requested Child Care Subsidies.

We will process your application and determine eligibility once you provide the following information.

CCSP application / provider information (you must complete this even if you are in a WorkFirst activity);

Provide proof of the last three months of household income (such as copies of pay stubs, child support, Social Security Income, Supplemental Security Income (SSI), and any other income received by someone in your family). Include your employment schedule. You don’t need to provide proof of income from cash assistance from the state (TANF).

If you are newly employed and have no pay stubs, we will accept a statement from your employer with a hire date, how much you are making (per hour, salary, etc.), and what your schedule will be. You must provide us a copy of your wage stubs within 30 days WAC 170-290-0012.

Proof of court or administrative ordered child support payments (if applicable) and verification of payments made.

Working Connections Child Care Only: If care is provided by a Family / Friends / Neighbors provider, the provider must meet the qualifications listed on the Application Part 2B and you must submit:

Legible copy of the provider’s picture identification, such as a driver’s license, state identification card, passport, or military identification;

Legible copy of the provider’s valid Social Security card;

Proof that the provider is legally able to work in the U.S., such as a Green Card, Resident Alien Card, or Employment Authorization Document (EAD);

Background Authorization form, DSHS 09-653. You may get this form from your WCCC authorizing worker.

No payment will be made for care provided prior to the date all background check results are received.

Please call the number below if you have questions.

Call Center Telephone Number:

Fax Number:

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

Seasonal Child Care

Applicants must:

Live in Adams, Benton, Chelan, Douglas, Franklin, Grant,

CHILD CARE SUBSIDY PROGRAMS (CCSP)

Kittitas, Okanogan, Skagit, Walla Walla, Whatcom or Yakima

CCSP Application

Counties;

Part 1. Application Information

 Work in a farm-based employment which includes cultivation,

production, harvesting or processing of fruit trees or crops.

Incomplete information may delay approval for

DATE

Services and payment. Type or print clearly.

APPLICANT’S NAME

CLIENT ID NUMBER

BIRTHDATE

APPLICANT’S ADDRESS

SSN (OPTIONAL)

TELEPHONE NUMBER

CITY

STATE

ZIP CODE

APPLICANT’S ETHNICITY RACE

APPLICANT’S GENDER

Male

Female

CHILDREN FOR WHOM YOU ARE RESPONSIBLE LIVING IN THE HOUSEHOLD

NAME (LAST, FIRST,

BIRTHDATE

MALE/

ETHNICITY

SSN (OPTIONAL)

U.S. CITIZEN OR

RELATIONSHIP TO

MIDDLE INITIAL)

FEMALE

LEGAL RESIDENT

APPLICANT

Yes

SPOUSE OR THE CHILD’S OTHER PARENT/GUARDIAN LIVING IN THE HOUSEHOLD (REQUIRED)

Are you married?

Yes

NAME

BIRTHDATE

SSN (OPTIONAL)

RELATIONSHIP TO

APPLICANT

ABOVE CHILDREN

APPLICANT

SPOUSE OR SECOND PARENT/GUARDIAN

NAME OF EMPLOYER, WORKFIRST ACTIVITY, OR SCHOOL

ADDRESS (EMPLOYMENT, WORKFIRST ACTIVITY,OR SCHOOL)

TELEPHONE NUMBER

DATE STARTED

TELEPHONE NUMBER

DATE STARTED

IF YOU ARE EMPLOYED, HOW OFTEN ARE YOU PAID AND YOUR

WAGE PER PAY PERIOD?

Weekly

Every two weeks

Weekly

Every two weeks

Twice a month

Monthly

Twice a month

Monthly

Do you pay court ordered child support?

Yes

Monthly amount: $

Do you have a court order to receive child support?

Yes

Monthly amount: $

MONTHLY SOURCES OF EARNED/UNEARNED INCOME FOR ALL FAMILY MEMBERS

Include COPIES (for the last three months):

NAME

SELF

Employment (gross, before taxes, include tips)

Self-employment

Temporary Aid to Needy Families (TANF)

Child support received

Social Security (SSI, SSA)

VA, Disability, L&I, or Unemployment benefits

Other (specify):

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

PARENT/GUARDIAN’S ACTIVITY SCHEDULE

	APPLICANT	SPOUSE OR SECOND PARENT/GUARDIAN
ACTIVITY (EMPLOYMENT, SCHOOL, WORFIRST ACTIVITY) INDICATE		ACTIVITY (EMPLOYMENT, SCHOOL, WORFIRST ACTIVITY) INDICATE
TIME WITH A.M./P.M.		TIME WITH A.M./P.M.

	WHAT IS YOUR SCHEDULE FOR EMPLOYMENT,	WHAT IS YOUR SCHEDULE FOR EMPLOYMENT,
	SCHOOL, WORKFIRST ACTIVITY?	SCHOOL, WORKFIRST ACTIVITY?
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What date will child care begin:

Applicant: One way, how long does it take you to travel from the childcare to your activity (work, school, etc.)?

Other parent/guardian: One way, how long does it take you to travel from the childcare to your activity (work, school, etc.)?

CHILDREN’S ACTIVITY SCHEDULE. FOR ADDITIONAL CHIDREN, ATTACH A SEPARATE PIECE OF PAPER WITH THEIR INFORMATION.

CHILDREN’S	SCHOOL SCHEDULE	CHILD CARE SCHEDULE
NAMES	(EXACT DAYS AND TIMES)	(EXACT DAYS AND TIMES)

Do you have a child with Special Needs?	Yes	No	If yes, please contact the Authorizing Worker for
			information about special needs payment rates.


		HEARING RIGHTS

If you disagree with this decision, you may request a hearing by contacting this office or write to Office of Administrative Hearings, P O Box 42489, Olympia, WA 98507-2489. You must request your hearing:

 On or before the effective date of this action or no more than 10 days after we send you notice of this action, IF you receive benefits now and you want them to continue, or

 Within 90 days of the date you receive this letter.

At the hearing, you have the right to represent yourself, be represented by an attorney or by any other person you choose. You may be able to get free legal advice or representation by contacting an office of legal services.

I declare under penalty of perjury that the information given by me in this declaration is true, correct and complete to the best of my knowledge and realize that willful falsification of this information by me may subject me to penalties as provided in Washington State Law. (RCW 74.08.055)

FIRST PARENT/LEGAL GUARDIAN’S SIGNATURE	DATE	SECOND PARENT/LEGAL GUARDIAN’S SIGNATURE	DATE

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

CHILD CARE SUBSIDY PROGRAMS (CCSP)

CCSP Application

Part 2A. Licensed Provider Information

(TO BE COMPLETED BY PARENT/GUARDIAN AND PROVIDER)

Type or print clearly. Incomplete information may delay approval for payment.

DATE

CALL CENTER TELEPHONE NUMBER

FAX NUMBER

1. PROVIDER’S NAME AND ADDRESS

CLIENT IDENTIFICATION NUMBER

The provider’s name and address given to us is public information and can
be given to anyone who requests it.
be given to anyone who requests it.			PARENT/GUARDIAN’S NAME

PROVIDER’S NAME			PROVIDER NUMBER

PROVIDER’S ADDRESS			PROVIDER TELEPHONE NUMBER

CITY	STATE	ZIP CODE	EXPECTED START DATE FOR CARE

2. TYPE OF CARE: CHECK THE CORRECT BOX IDENTIFYING THE TYPE OF CARE YOU PROVIDE. PROVIDER COMPLETE SECTIONS 3 AND 4.

Licensed Child Care Center

PROVIDER’S SSN OR FEDERAL TAX IDENTIFICATION NUMBER

Licensed Family Home Child Care

PROVIDER’S SSN OR FEDERAL TAX IDENTIFICATION NUMBER

3.ENTER THE DAYS AND TIMES YOU WILL PROVIDE CARE FOR THE FOLLOWING CHILDREN (PLEASE USE SECTION FIVE FOR ADDITIONAL CHILDREN YOU CARE FOR)

NAMES

BIRTHDATE

DAYS AND TIMES CARE WILL BE PROVIDED, SPECIFY BEFORE AND AFTER SCHOOL TIMES

4. LICENSED PROVIDER: ENTER YOUR DAILY RATES

What are the usual rates you charge to parents / guardians?

This information must be provided before payment is authorized.

INFANT (ZERO	ENHANCED	TODDLER (18 – 29
– 11 MONTHS)	TODDLER (12	MONTHS)
$	– 17 MONTHS)	$
	$
PRESCHOOL	SCHOOL AGE	REGISTRATION FEE
(30 MONTHS –	(FIVE – 12	NONE
FIVE YEARS	YEARS)	NONE
FIVE YEARS	YEARS)	ONE-TIME
NOT IN	$	ONE-TIME
NOT IN	$	YEARLY
SCHOOL)		FIELD TRIP FEE
$		FIELD TRIP FEE
$

IF YES, AMOUNT:

PER CHILD PER FAMILY

$PER MONTH

RATE

Contact the Call Center for payment rates for children with special needs.

I understand completing this form does not guarantee payment. If child care is authorized, I agree to child care payment at my usual rate or the DEL rate, whichever is less.

PROVIDER’S SIGNATURE

Director

Owner

Other

DATE

TELEPHONE AND FAX NUMBER (INCLUDE AREA CODE)

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

WORKING CONNECTIONS CHILD CARE (WCCC)

WCCC Only Application

Part 2B. Family / Friends / Neighbors Provider Information

(TO BE COMPLETED BY PARENT/GUARDIAN AND PROVIDER)

Type or print clearly. Incomplete information may delay approval for payment.

DATE

CALL CENTER TELEPHONE NUMBER

FAX NUMBER

SECTION 1. PROVIDER’S NAME AND ADDRESS

CLIENT IDENTIFICATION NUMBER

The provider’s name and address given to us is public information and can be
given to anyone who requests it.				PARENT/GUARDIAN’S NAME

	PROVIDER’S NAME			PROVIDER NUMBER

	PROVIDER’S ADDRESS			PROVIDER TELEPHONE NUMBER

	CITY	STATE	ZIP CODE	EXPECTED START DATE FOR CARE

		SECTION 2. TO BE COMPLETED BY PARENT APPLYING FOR CHILD CARE

1. Is the provider your child (natural, step, adopted, or foster) aged 18 through 20 years old.

2. Is the provider your parent (natural, step, adopted, or foster). Yes No If yes to #2, please check the box below that applies to you.

Yes

Are you :

Widowed.

Divorced.

Married, separated, or never married.

Living with my disabled spouse who is unable to care for my child for at least four continuous weeks in a calendar quarter.

Neither 1 or 2 apply.

SECTION 3. TO BE COMPLETED BY FAMILY / FRIENDS / NEIGHBORS PROVIDER

PROVIDER’S SSN		RELATIONSHIP TO CHILD	PROVIDER’S EMAIL ADDRESS

PROVIDER OVER 18?		BIRTH DATE	US CITIZEN OR A RESIDENT LEGALLY ABLE TO WORK IN THE U.S.?
Yes	No		Yes	No

You must:

Provide care only in the children’s home. Care may be in the provider’s home if he/she is one of the following relatives to the children: aunt, uncle, grandparent, sibling living outside of the home, great aunt, great uncle, or great grandparent.

Do you live with the child you are providing care for? Yes No

Care will be done in the children’s home. Go to Section 5. Care will be done in the provider’s home. Complete Section 4.

SECTION 4. PROVIDER COMPLETES IF THE CHILD CARE OCCURS IN YOUR HOME AND THE CHILD DOES NOT LIVE THERE

When care occurs in your home and the child does not live there, provide the department with the names, birth dates, and sex offender status of all persons, 16 years of age or older, who live with you:

NAME	BIRTH DATE	REGISTERED SEX OFFENDER
1.		Yes	No
		Yes	No

2.		Yes	No
		Yes	No

3.		Yes	No
		Yes	No

4.		Yes	No
		Yes	No

Failure to report a sex offender in the provider’s home where care is provided will result in permanent disqualification of the provider.

WAC 170-290-0160

I certify the persons listed above are the only individuals, 16 years of age or older, who reside with me. I understand these individuals will be subject to the same background inquiry process as me. I also understand if another person, 16 years of age or older, moves into my home while I am an authorized provider for WCCC, I must immediately notify the parent.

PROVIDER’S SIGNATURE

DATE

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

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filling out dshs child care application forms part 1

Put the asked particulars in the Please call the number below if, Call Center Telephone Number, Fax Number, and CCSP APPLICATION DSHS REV part.

dshs child care application forms Please call the number below if, Call Center Telephone Number, Fax Number, and CCSP APPLICATION DSHS REV fields to fill

You should be demanded specific relevant details if you want to prepare the Seasonal Child Care, Applicants must, CHILD CARE SUBSIDY PROGRAMS CCSP, Live in Adams Benton Chelan, Kittitas Okanogan Skagit Walla, Work in a farmbased employment, DATE, APPLICANTS NAME, CLIENT ID NUMBER, BIRTHDATE, APPLICANTS ADDRESS, SSN OPTIONAL, TELEPHONE NUMBER, CITY, and STATE ZIP CODE box.

Completing dshs child care application forms part 3

The NAME, BIRTHDATE, SSN OPTIONAL, RELATIONSHIP TO APPLICANT, RELATIONSHIP TO ABOVE CHILDREN, NAME OF EMPLOYER WORKFIRST, NAME OF EMPLOYER WORKFIRST, APPLICANT, SPOUSE OR SECOND PARENTGUARDIAN, ADDRESS EMPLOYMENT WORKFIRST, ADDRESS EMPLOYMENT WORKFIRST, TELEPHONE NUMBER, DATE STARTED, TELEPHONE NUMBER, and DATE STARTED field will be your place to indicate the rights and responsibilities of both sides.

dshs child care application forms NAME, BIRTHDATE, SSN OPTIONAL, RELATIONSHIP TO APPLICANT, RELATIONSHIP TO ABOVE CHILDREN, NAME OF EMPLOYER WORKFIRST, NAME OF EMPLOYER WORKFIRST, APPLICANT, SPOUSE OR SECOND PARENTGUARDIAN, ADDRESS EMPLOYMENT WORKFIRST, ADDRESS EMPLOYMENT WORKFIRST, TELEPHONE NUMBER, DATE STARTED, TELEPHONE NUMBER, and DATE STARTED fields to complete

Check the fields VA Disability LI or Unemployment and then fill them out.

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Form Dshs 14 417 – Fill Out and Use This PDF

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