Form Dshs 14 417 – Fill Out and Use This PDF

PARENT/GUARDIAN’S ACTIVITY SCHEDULE

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.

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)

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

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

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

4. LICENSED PROVIDER: ENTER YOUR DAILY RATES

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.

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

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

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.

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:

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.

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

SECTION 5. TO BE COMPLETED BY FAMILY / FRIENDS / NEIGHBORS PROVIDER

Family / Friends / Neighbors providers can bill the state for no more than six (6) children at the same time.

ENTER DAYS, TIMES, AND AT WHAT RATES YOU WILL PROVIDE CARE FOR THE CHILD(REN).

CONTACT THE CALL CENTER FOR PAYMENT RATES FOR CHILDREN WITH SPECIAL NEEDS.

SECTION 6. TO BE READ AND SIGNED BY THE PROVIDER

Provider Responsibilities:

Complete a background check authorization. If you care for a child in your own home, also submit a completed background authorization for anyone 16 years of age or older who lives with you or moves into your home.

Report to DSHS within 24 hours any criminal convictions or pending charges against you or anyone 16 years or older in hour home if care is provided in your home.

Report to DSHS within 10 days if you change your legal name, address, or telephone number.

Provider Eligibility:

Be 18 years of age or older and a citizen or legal resident of the United States.

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

Not have a disqualifying criminal background under WAC 170-290-0160 or WAC 170-290-0165.

Be physically and mentally healthy enough to meet all the needs of the child in care. If staff ask for it, the parent(s) must provide written proof you are physically and mentally healthy enough to be a safe child care provider.

Be able to care for the child without using physical punishment or mental abuse.

Provide care to the child in a safe home.

Be informed about basic health practices, prevention and control of infectious disease, and immunizations.

Provide constant care, supervision, and activities based on the developmental needs of the child.

Immediately report, to the parent, any notice of criminal convictions or pending charges against yourself or of anyone in the household, 16 years of age or older, when care occurs outside the child’s home.

Not be the child's biological, step or adoptive parent, legal guardian, adult acting in loco parentis, or the spouse of any of these individuals.

Attendance Records:

Records must:

O Show both days and times you cared for each child

O Have the parent/guardian sign and date the attendance records at least weekly O Be kept for five (5) years

O Be provided within 14 days if DSHS or DEL asks to see them

Billing:

You will not be paid for child care provided prior to the date all background check results are cleared by DSHS. If you provide care before your background check clears, the family is responsible for paying you.

You may bill DSHS for no more than six (6) children during the same hours of care.

Review daily attendance records in order to determine the number of units to bill based on a child’s attendance and authorization.

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

SECTION 6. CONTINUED

Service Employees International Union Local 925 (SEIU 925)

SEIU 925 represents Family/Friends/Neighbor providers. The Collective Bargaining Agreement outlines the provisions and benefits for SEIU 925 members. Members pay dues of 2 percent of the child services paid by the state. Dues are capped at a maximum of $50 per month.

Additional information is available in: A Guide for Family, Friends and Neighbors Child Care Providers located at: http://www.del.wa.gov/requirements/info/subsidy.aspx

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 State rate, whichever is less. I understand that payment cannot occur prior to the date the department receives all background check results. I have read and understand Section 6 of this form.

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

SECTION 7. TO BE READ AND SIGNED BY THE PARENT

I, as the parent/guardian, certify my Family / Friends / Neighbors provider meets the requirements listed above. I understand:

If I cannot make these assurances, payment will not be authorized.

Certain background information may disqualify my provider. It is my provider's responsibility to immediately tell me if they, or any person, 16 years of age or older living with the provider, when care occurs outside of the child's home are charged or convicted of any crime. I am then responsible to immediately tell my WCCC authorizing worker.

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

I must notify CCSP staff, within five days, if this provider stops child care.

My provider will not be paid for the care of more than six children at the same time (same hours and days).

I may not have more than three Family/Friends/Neighbors providers authorized for WCCC payment at the same time during my eligibility period. Only one of these three providers can be a back-up (alternate) provider. I may use a licensed/certified provider for back-up care.

As the employer of your Family/Friends/Neighbors provider, it is your responsibility to have your provider complete the USCIS Employment Eligibility Verification Form I-9.

O All U.S. employers must complete and retain a Form I-9 for each individual they hire for employment in the United States.

O This includes citizens and noncitizens.

O On the form, the employer must examine the employment eligibility and identity document(s) an employee presents to determine whether the document(s) reasonably appear to be genuine and relate to the individual and record the document information on the Form I-9.

O The list of acceptable documents can be found on the last page of the form. The form and instructions can be found at: http://www.uscis.gov/i-9

If the living situation changes between you and the provider please report this immediately (this type of change can impact what tax document will be sent to the providers for their service).

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