From Ccp 2145 Form – Fill Out and Use This PDF

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY																								CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CalWORKs CHILD CARE REIMBURSEMENT REPORT
Instructions:
																										COUNTY USE ONLY
• If you have approved child care costs and want a payment, fill out and return this report to your child care worker each
	month. If a complete report is not received each month, your child care benefits may be late, denied, or stopped.																									Date Received:
• PART A must be filled out by you and PART B, on the back of this form, must be filled out by each child care provider.																										Worker Number:
	If needed, ask your worker for more copies.
PART A - PARTICIPANT FILLS IN THIS SECTION.																										Case Name:
	MONTH/YEAR OF REQUEST					NAME (FIRST, MIDDLE, LAST)									CASE NAME, IF DIFFERENT						HOME PHONE
1.					2.																(	)
																										Case Number:
						ADDRESS (STREET, CITY, STATE, ZIP CODE)
WORK PHONE, IF APPLICABLE
(	)																									(✔) the boxes below
																										when the status for each
3. List the number of hours you worked or participated in a CalWORKs county approved activity each day in the
																										has been verified.
	month. (Do not write in the blanks on days you did not go to work or did not participate in a county approved
	activity.) Attach proof.
		1		2	3	4		5	6	7	8	9	10	11		12	13	14	15	16
																										■	Total Hours Verified
		17		18	19	20		21	22	23	24	25	26	27		28	29	30	31		TOTAL HOURS
																										■	Evening/weekend
																											Hours

4.List your normal work or CalWORKs county approved activity hours.

For example: Monday-Thursday, 8:00 a.m. to 5:00 p.m.; Saturday, 1:00 p.m.-5:00 p.m., Sunday 1:00 p.m. - 4:00 p.m. and 6:00 p.m. - 9:00 p.m.

5.It takes me ________hours _________minutes each day to go to and from my child care provider(s) and where

I go to work and/or other CalWORKs county approved activity.							For License Exempt
CHILD’S NAME	BIRTHDATE	AGE	PROVIDER’S NAME		AMOUNT PAID		Provider
							■	Applied For Trustline
							■	Trustline Registered
							■	Exempt From
								Trustline
6. My child care provider has changed since my last request for a child care payment.				■ YES		■ NO	■	RMR Changed
(If “yes”, your new provider must be approved before you can get a payment.)
7. I am receiving child care subsidies from another source.				■ YES		■ NO
(If “Yes”, please describe)

CERTIFICATION

I understand that:

•I am certifying I worked or participated in other CalWORKs county approved activity on the days and hours listed above.

•Any statements made on this form are subject to investigation and verification.

•I must report to my child care worker any time a parent of a child receiving child care moves into my home or another child moves into my home, including newborns.

•I must report if my family income has reached or is over the following family fee income thresholds and has changed since last reported to child care:

Family size*	Income per Month	Family Size	Income per month
1-2	$1820 per month	3	$1950 per month
4	$2167 per month	5 or more	$2513 per month

*Family size includes adults and children related by blood, marriage, or adoption that live in the home of the child receiving child care.

•I have the right to choose the child care provider who is best for me and my child(ren).

•The provider must have a license or be exempt from having a license in order for me to get a child care payment.

•If I choose a license exempt child care provider, (s)he must apply for or be Trustline registered and meet Health & Safety Certification criteria unless exempt.

•The county does not act as the child care provider’s employer, and does not have a business relationship with the child care provider when a child care payment is paid.

•If I choose child care in my home, I may be considered the employer and am responsible for complying with any applicable federal and state employment-related laws.

•I must pay back any child care payments I am not entitled to get.

I declare under penalty of perjury under the laws of the State of California that the information contained in PART A on this report is true and correct.

CCP 2145 (5/04) RECOMMENDED

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PART B - ONLY CHILD CARE PROVIDER FILLS IN THIS SECTION.

Month/Year of Request:_____________

1.

PROVIDER’S NAME (FIRST, MIDDLE, LAST) OR NAME OF FACILITY

SOCIAL SECURITY NUMBER/TAX ID NUMBER (OPTIONAL)

ADDRESS WHERE CARE IS PROVIDED

NUMBER

STREET

CITY

STATE

ZIP CODE

PHONE

(

)

BILLING ADDRESS, IF DIFFERENT THAN ABOVE.

PHONE

ADDRESS

NUMBER

STREET

CITY

STATE

ZIP CODE

(

)

2. I provided child care in:

■ My Home

■ Child’s Home

■ Family Day Care Home

■ Day Care Center

(■ Small

■

Large)

for the family listed on the front in___________________(Month/Year), for the following child(ren):

Family fee paid

Child’s Name

Amount Charged

Rate Charged

Specify How Charged

Per Child

(per hour, day, week, month)

A.

B.

C.

D.

Total

3.List the number of hours you provided child care to each child for each day of the month:

Child

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

TOTAL

A.

B.

C.

D.

Other information:

4.For the boxes listed below, check (✔) the one that applies to you.

■I certify I am a licensed child care provider and my valid license number is___________________________.

■I certify I do not need a child day care license because (only one needs to apply):

■I am related to the child: Child A:_______________, Child B:______________, Child C:______________, Child D:______________.

(RELATIONSHIP)

(RELATIONSHIP)

(RELATIONSHIP)

(RELATIONSHIP)

■I care for my own family’s child(ren) and the child(ren) from only one other family at any one time.

■The facility is a public or private exempt school which operates a program before and/or after school for school-age children, providing the program offered by a school is operated by the school and run by qualified teachers employed by the school recreation program or school district.

■The facility is a public or private recreation program.

CERTIFICATION

•I declare that I am at least 18 years of age.

•I declare that I provided the child care listed above and that the hours of care and total monthly costs listed above are true and correct.

•I understand that if I am license exempt, I must apply for Trustline and Health & Safety certification registration unless I am an aunt, uncle, grandparent of a child(ren) in my care or a school or recreation facility.

•I understand that the social security number, provided above, may be used to check whether I am also receiving CalWORKs, Food Stamps, and/or Medi-Cal benefits and that I must report this income to my eligibility worker.

•I understand that I must charge the rate I charge for participant’s children listed on the front, the same or lower child care rates that I charge other clients for the same service.

•I understand that the County does not act as my employer or have a business relationship with me when I get a child care payment.

•I understand that failing to report facts or giving wrong or incomplete facts on this report can result in legal prosecution with penalties of a fine, imprisonment or both.

I declare under penalty of perjury under the laws of the State of California that the information contained in PART B on this report is true and correct.

CCP 2145 (5/04) RECOMMENDED

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