Form ST1-05 PDF Details

Navigating the complexities of child care assistance in Los Angeles County is an essential process for many families, particularly those involved in the CalWORKs Stage 1 Child Care program. The ST1 05 form stands at the center of this navigation, serving as a vital application that connects participant families with the child care services they desperately need. This comprehensive document not only captures participant information and child care requirements but also outlines the conditions under which child care services can be approved, paid for, and subsequently maintained. Detailed within its pages are the responsibilities of both the child care provider and the recipient, including the necessity for providers to be eligible and possibly Trustline-registered, depending on their licensure status. Critical to both parties is the mutual understanding that the application process entails a thorough review by either Los Angeles County or a designated Child Care Agency, with a promise of notification regarding approval or denial within ten days of a fully completed application package submission. Moreover, the form encapsulates the financial implications for the participant, elucidating potential costs that may arise, such as co-payments and family fees, alongside the conditions for subsidy eligibility and the repayment obligations for any overpayments. The expectations set forth in the participant and provider declarations encapsulate a commitment to honesty, regulatory compliance, and the continual communication of any changes that could affect the provision of child care services.

QuestionAnswer
Form NameForm ST1-05
Form Length2 pages
Fillable?Yes
Fillable fields47
Avg. time to fill out9 min 58 sec
Other namesst1 05 child care provider, maof provider, st1 provider services application, maof form template

Form Preview Example

CalWORKs Stage 1 Child Care

AGENCY NAME

Participant - Provider Services Application

ADDRESS

 

PHONE #

 

401 N. GARFIELD AVE, MONTEBELLO CA 90640

OFFICE USE ONLY

ATTN: ______________

This is an application for child care services. This application must be approved by Los Angeles County or the Child Care Agency and your provider must be determined eligible before any child care expenses can be paid. The County or the Child Care Agency will send you a notice informing you if your child care is approved or denied within 10 days of receipt of a completed application package. Do not use white out when completing this form. Please make a copy for your files.

A.CASE INFORMATION: Must be completed by the Participant or Child Care Agency. (Please Print)

1.

Participant Name:_____________________________________

2.

CalWORKs Case #:

______________________________

3.Address (include city & zip code) __________________________________________________________

4.Daytime Phone #: (___) _______________________ Cell Phone #: (___)________________________

5. E-mail Address (optional): ____________________________ Text messages OK?

Yes

No

B.CHILD CARE NEEDED: Must be completed by the Participant. Questions? Call __________________.

1.Please list the name and birth date of all your children up to age 12 (or under 18 if special needs that will require a case-by-case evaluation) who will be in child care with the provider listed on the back of this form.

You must fill out a separate form for each provider.

Child’s Name

Date Of Birth

Child’s Name

Date Of Birth

a)_________________________________________ b) _________________________________________

c)_________________________________________ d) _________________________________________

e)_________________________________________ f) __________________________________________

2.I need child care by date (mm/dd/yy): ___________________________.

3.I am asking for all the child care hours I am eligible for based on my approved activity and travel time._________

(Please initial)

C.PARTICIPANT DECLARATION: Please read carefully and sign below.

I understand that:

1.I have the right to choose the child care provider who I want. If I change providers, I must tell the County or the Child Care Agency immediately. If I don’t report the change, they won’t be paid.

2.I must notify the County or Child Care Agency within 5 calendar days of any changes to my income, family size, residence, employment or reason for needing child care services. If I do not, then it may affect my child care services.

3.If I choose an unlicensed child care provider, he/she must be Trustline-registered. This means he/she must pass a

criminal background check. The home where child care is provided must be a safe place to care for my child (Health and Safety Self-Certification criteria). We won’t pay until he/she meets these rules.

4.License-exempt centers, such as before or after school programs, YMCA, and/or my child’s aunt, uncle, or grandparent do not have to be Trustline-registered and are exempt from Health and Safety Self-Certification.

5.I must pay back any child care payments I am not entitled to receive.

6.The County or Child Care Agency is not my child care provider’s employer.

7.I may have to pay a family fee (a share of the cost of child care based on my income). The County or Child Care Agency will notify me if I must pay a family fee.

8.If the County or Child Care Agency cannot pay what my provider charges because it is over the limit, I will have to pay the difference (co-payment) to the provider. I can also change to a provider that charges less.

9.The CalWORKs Stage 1 Child Care Program does not pay for school tuition.

10.For families who do not have a set schedule for work and/or school, the County or Child Care Agency cannot pre- approve a set number of hours. The Child Care Agency will pay my provider at the end of the month based on my reported and verified hours. I will be responsible to pay for any child care hours over that amount.

11.Information on this form or about my eligibility may be shared with other County agencies, the State of California, the Federal Government, independent auditors, or others, as necessary for the administration of the program or to comply with State and Federal laws.

12.This application is subject to change, as needed, to comply with State or Federal regulations.

I acknowledge that I have read, understand, and agree to comply with the above terms. I declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained on this page is true and correct to the best of my knowledge.

Participant’s Signature: ______________________________ Date: _______________________

ST1-05 (REV. 7/11) [CalWORKs Stage 1 Child Care Participant-Provider Services Application]

CalWORKs Stage 1 Child Care Participant - Provider Services Application

This is an application for child care payment. This application must be approved by Los Angeles County or the Child

Care Agency and you (the selected provider) must be determined eligible before any child care expenses can be paid. The County or the Child Care Agency will send a notice informing the parent if payment for child care is approved or denied within 10 days of receipt of a completed application package. Do not use white out when completing this form. Please make a copy for your files.

D.PROVIDER INFORMATION: Must be completed by Provider. (Please Print)

1.

Provider/Facility Name: ________________________________________________________________

2.

Address (include city & zip code):

____________________________________________________

3.Phone #: (___)______________________ E-mail Address (optional): ____________________________

4.Type of Care: Please select the type of Provider.

Licensed Center

Before or After-School Program

Licensed Family Child Care Home

License-Exempt Center

License-Exempt Individual

5.Provider Rates/Facility License (Rates may only be changed once per year)

Licensed Centers, Family Child Care, Before or After-School Programs, and License-Exempt Centers, please check the one that applies.

My rate sheet and license, if required, are attached.

I would like the Child Care Agency to use my rate sheet and license, which I previously submitted.

OR

License-Exempt Individuals, please complete the following:

a.Provider’s Relationship to children:

No relation

Grandparent

b.Child care will be provided in:

Aunt/Uncle

Other relative: ____________________________

Child(ren)’s Home:

My Home

Other: ________________________________________________

License-Exempt individuals only: (Rates may only be changed once per year)

RATES FOR LICENSE-EXEMPT INDIVIDUALS

Please provide an amount for all of the following:

1)

Rate Per Hour $_______________

2) Rate Per Day $______________

3)

Rate Per Week $______________

4) Rate Per Month $______________

The Child Care Agency will determine your rate/payment based on the child’s age and number of hours child care is provided.

E.PROVIDER DECLARATION: Please read carefully and sign below.

I understand that:

1. I am not the parent, legal guardian or a member of the TANF/CalWORKs assistance unit of the child(ren) for whom I will provide care.

2. If I am a license-exempt individual, I only care for children who are relatives or I only take care of my own child(ren) and the child(ren) from only one other family, during the same hours.

3. If I am a licensed provider, the child care rates and fees I charge for families who use County or Child Care Agency subsidies are the same as the rates I charge private-pay families for the same service.

4. Neither the County nor the Child Care Agency is my employer.

5. If I am license-exempt, I must be Trustline-registered and complete a Health & Safety Self-Certification before any payments for subsidized child care can be made unless I am an aunt, uncle, or grandparent, of the child(ren) in my care, or a school or recreation center.

6. If the child is absent for 5 consecutive authorized days of child care, I must notify the Child Care Agency within 24 hours of the 5th day of absence.

7. If the County or Child Care Agency cannot pay my entire fee(s) based on Regional Market Rate ceilings, the parent will

be responsible to pay me the difference directly (co-payment).

8.For families on variable schedules, the County or Child Care Agency cannot pre-approve a set number of hours. My payment will be determined based on the family’s verified need at the end of the month. The parent will be responsible for any difference between the verified hours of child care paid for by the Child Care Agency and any additional hours of child care used by the parent in the same month.

9.Information on this form or about my eligibility may be shared with other County agencies, the State of California, the Federal Government, independent auditors, or others, as necessary for the administration of the program or to comply with State and Federal laws.

10.This application is subject to change as needed in order to comply with State or Federal regulations.

I acknowledge that I have read, understand, and agree to comply with the above terms. I declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained on this page is true and correct to the best of my knowledge.

Provider’s Signature: _________________________________

Date: __________________

Page 2 of 2

ST1-05 (REV. 7/11) [CalWORKs Stage 1 Child Care Participant-Provider Services Application]

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