Ssn Details

Form Dshs 14 417 is an annual report that the Department of Social and Health Services (DSHS) in Washington State requires all licensed SCHs to complete. The form asks for various information about the center, including demographics, services offered, payroll data, and more. Completing this form is important not just because it's required by DSHS, but also because the information it provides can be used to help improve your center. In this blog post, we'll provide a brief overview of what's required on Form Dshs 14 417 and offer some tips for completing it accurately. Stay tuned for our next post, where we'll go into more detail about each section of the form.

In the table, there's some good information concerning the form dshs 14 417. There, you'll obtain the information regarding the PDF you would like to fill in, including the likely time required to complete it along with other data.

QuestionAnswer
Form NameForm Dshs 14 417
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other nameschild care dshs, DSHS, dshs child care fax number, WorkFirst

Form Preview Example

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

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

Are you married?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

BIRTHDATE

 

 

 

 

 

SSN (OPTIONAL)

 

RELATIONSHIP TO

 

 

RELATIONSHIP TO

 

 

 

 

 

 

 

 

 

 

APPLICANT

 

 

ABOVE CHILDREN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE OR SECOND PARENT/GUARDIAN

 

 

 

NAME OF EMPLOYER, WORKFIRST ACTIVITY, OR SCHOOL

 

 

 

 

NAME OF EMPLOYER, WORKFIRST ACTIVITY, OR SCHOOL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS (EMPLOYMENT, 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

 

 

 

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

 

WAGE PER PAY PERIOD?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

No

Monthly amount: $

 

 

 

 

Do you have a court order to receive child support?

 

Yes

 

No

Monthly amount: $

 

 

 

 

 

 

MONTHLY SOURCES OF EARNED/UNEARNED INCOME FOR ALL FAMILY MEMBERS

 

 

 

Include COPIES (for the last three months):

 

NAME

 

 

 

 

 

NAME

 

 

NAME

 

 

 

 

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.

 

 

 

 

 

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)

ONE-TIME

NOT IN

$

YEARLY

SCHOOL)

 

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

No

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.

3.

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

 

 

 

 

 

 

2.

 

Yes

No

 

 

 

 

 

 

3.

 

Yes

No

 

 

 

 

 

 

4.

 

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)

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).

 

 

 

THE USUAL

CHOOSE ONE OF THE

 

 

 

HOURLY

TWO BOXES BELOW FOR

CHILD’S FIRST AND LAST

 

DAYS AND TIMES CARE WILL BE

RATE I

EACH CHILD.

BIRTHDATE

PROVIDED, SPECIFY BEFORE AND AFTER

CHARGE TO

MY RATE IS MORE

I WANT MY

NAME

 

SCHOOL TIMES

CARE FOR

THAN THE STATE

LESSER

 

 

RATE FOR THIS CHILD.

HOURLY

 

 

 

THE CHILD

 

 

 

I WANT THE MAXIMUM

RATE FOR

 

 

 

IS:

STATE RATE.

THIS CHILD.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

PROVIDER’S SIGNATURE

DATE

Non-relative caretaker Relative caretaker

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)

PARENT/GUARDIAN’S SIGNATURE

CCSP APPLICATION

DSHS 14-417 (REV. 02/2014)

DATE

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .