Workforce Solutions - Child Care Services (CCS) Eligibility Requirements

Workforce Solutions - Child Care Services (CCS) Eligibility Requirements Dear Parent(s)/Guardian(s); We are pleased to provide this information and ap...
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Workforce Solutions - Child Care Services (CCS) Eligibility Requirements Dear Parent(s)/Guardian(s); We are pleased to provide this information and application for Child Care Services to assist you with the cost of care for your child/ren while you work, are in training or to continue your education. Please complete, sign and date all the forms on this packet that apply to your household and return with all the required verifying documentation. Once the complete eligibility packet is received, a Child Care Specialist will review the information submitted and determine if you qualify for child care services. Eligibility Requirements Your family may be eligible for child care assistance if: 1. 2. 3. 4. 5.

You reside in Hidalgo, Willacy, Starr County; and You have a child(ren) under the age of 13 (or a child(ren) with disabilities under the age of 19); and Your family’s income does not exceed 85% of the state median income (see below); and Each child receiving child care is a US citizen or legal resident of the United States; and The family requires child care to participate in training, education, and/or a combination of employment activities a minimum of 25 hours per week for a single-parent family or 50 hours per week for a two-parent family. Gross Monthly Income October 01, 2014 – September 30, 2015

2

Maximum Monthly 85% State Median $3,264

3

$4,032

4

$4,799

5

$5,567

6

$6,335

7

$6,479

8

$6,623

9

$6,767

10

$6,911

Family Size

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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CCS Eligibility Packet Checklist Use the following checklist as a guide to be certain you complete the entire Child Care Services Eligibility Packet. You may go to your nearest Workforce Solutions Career Center to use a computer, printer, and/or fax machine free of charge. To locate the Workforce Solutions Career Center nearest you, please visit www.wfsolutions.org Once complete, the application and verification documents may be mailed, faxed or hand-delivered to the address below.

Mail or Hand Deliver Workforce Solutions – Child Care Services Workforce Solutions – Child Care Services WFS Mission Office WFS Weslaco Office 901 Travis St., Suite 7 1600 N. Westgate, Suite 400 Mission, Texas 78572 Weslaco, Texas 78596 Direct: (956) 519.4300 Direct: (956) 969.6100 Fax: 1.866.580.6089 Fax: 1. 866.890.5452 Hours: M-F, 8am – 5pm PLEASE BE CERTAIN TO SIGN, DATE AND KEEP COPIES OF ALL THE DOCUMENTS YOU SUBMIT.

Child Care Eligibility Certification Application – This is your official application. You must ensure this application is complete and accurate or your child care assistance may be denied. You must ensure that the application:  Is completely filled out  Is completed in ink only (no pencil)  Is signed and dated (the day you submit the application)  Does not have “whiteout” corrections Proof of Physical Address  Current State Driver License  Current Picture Identification Card  Water, Light, or Gas Bill  Texas Department of Health & Human Services Letter Parent Identity: You must submit the following for each parent in the household to verify parent identity.  Birth Certificates  Social Security Cards (optional)  Valid Driver’s License or State Issued Picture ID Age & Citizenship –Child (ren): You must submit the following for each child in your household to verify age/citizenship  Birth Certificates (U.S. or its possessions)  U.S. Passport (must be current)  Hospital or public health birth records (U.S. or its possessions). Note: We cannot accept birth facts.  Church or Baptismal Record (U.S. or its possessions)  TANF, food stamp benefits, Medicaid, or other related public assistance records “What if my child was born in the United States, but I was not?” o Answer: Only the child receiving assistance is required to be a US Citizen or Legal Resident “What if I do not have any of the above documents to verify age/citizenship?” o Answer: Child Care Assistance cannot be authorized for that specific child. Note: If you do not have any of the above mentioned documents, please contact our office @ (956)519.4333 or (956)969.6144 Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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Child Support: You must supply the following to verify child support cooperation  Office of the Attorney General Child Support Income Verification Form (Page 12-13) www.childsupport.oag.state.us.tx, and/or  Parental Responsibility Agreement (PRA) – Informal Child Support Form (Page 14) Note: Verification of child support & paternity is required for all children in the household under 18 years of age (Page 12) Household Income: You must submit the following to verify your household income. If employed and paid by check:  Copies of last (4) check stubs for each parent in the household, and a  Work Schedule Verification form completed by the employer for each parent (Page 7) If new hire:  Wage Verification form - sign the top section of the form and have your employer complete, sign and date form (Page 6), and  Provide copies of check stubs, if available *In addition, please submit verification of all household members’ income. Note: Dependent(s) over 14 years of age not attending school and is working; must report their earnings. Note: If you or your spouse are self-employed or paid in cash (Page 8-10), For any questions on this please contact our office @ (956)519.4333 or (956)969.6144 If participating in a Job Training/Educational Program: You must supply the following to verify your participation in a Job Training/Educational Program. If attending a college or university:  Current School Schedule, and  Current Transcript If attending a vocational school:  Enrollment Letter from the school, and  School or Training Schedule Verification Form -completed by the training/education provider (Page 11) For High School or GED Students only:  Program enrollment form, or  Letter from school verifying enrollment, and  School or Training Schedule Verification Form -completed by the training/education provider (Page 11) Child (ren) School Attendance: You must provide the following to verify attendance for all children in the household under 18 years of age. (Page 22)  Self-Attestation of School attendance Child Care Automated Attendance (CCAA): You must sign and return the following to verify your understanding of your responsibilities in using the CCAA system and to receive CCAA cards for yourself and/or up to (3) designees. (Page 19-20)  Parent Agreement for use of CCAA  CCAA Primary and Secondary Cardholder Request Form Reporting absences and attendance daily is a CCS requirement. Failure to do so will result in termination of your child care services. Parent Acknowledgement of Rights and Responsibilities (PARR): You must sign and return the PARR which informs you of your rights and responsibilities while receiving this assistance (Page 15-18) , including:  Responsibilities to report changes within 10 days of occurrence, and  Consequences for not reporting changes as well as for fraud and abuse of program services. Orientation to Discrimination Complaint Procedures Form: You must sign and return this Form which informs you of your rights and procedures for filing complaints related to services received. (Page 23-24)

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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CHILD CARE ELIGIBILITY CERTIFICATION APPLICATION

TWIST ID#:

CHILD CARE ELIGIBILITY CERTIFICATION APPLICATION

TWIST #

1.Applicant Name (First, MI, Last) / Nombre: (Inicial, apellido)

Social Security (optional) / Número de seguro social (opcional)

Date of Birth / Fecha de nacimento

Physical Address / Dirección del Domicilio

City / Ciudad:

Zip Code / Código postal

County / Condado

Mailing Address / Dirección postal

City / Ciudad

Zip Code / Código postal

Sex: Sexo

Other Contact # w/Name and Relation / Teléfono alternativo, nombre y relación:

Family Size/Número de miembros que componen la unidad familiar:

Home Phone # / Teléfono del hogar

Cell Phone # / Teléfono cellular

Yes/Si

M M

F F

No

Do we have your consent to contact you via text message/ Tenemos su consentimiento para ponerse en contacto con usted través de mensajes de texto

Are you a Veteran or Spouse of a Veteran? Yes No Es usted veterano o esposo/a de un veterano? Si No

E-Mail Address

/ Correo Electrónico

Foster Youth

Yes

No

Highest Grade Completed/Nivel de educación Migrant

Yes

No

Race/Raza

Hijos adoptivos Si No Marital Status: ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed Estado civil: ( ) Casado ( ) Soltero ( ) Divorciado ( ) Separado ( ) Viudo ( )

Migrante Si No Food Stamps Yes No Recibe estampillas? Si No

Place of Employment/Lugar de Empleo

Work Schedule/Horario de Trabajo

Hire Date/ Fecha Contratado

Other Income/Otros Ingresos

Hourly Pay Rate/ Salario por Hora

Work Phone #/ Teléfono del Trabajo Pay Frequency/Frecuencia de Pago Weekly

Bi-Weekly

Monthly Bi-Monthly Name of School or Training Institution/ Nombre de la escuela o Institución de formación

Self Employed/Autónomo(a)

Income before taxes / Ingresos antes de impuestos $ __________________________ School Schedule/Horario Escolar

Tips:$_________ Bonus:$_________ Commission $__________ None Semester Hours/Hours Semestre

Hispanic/ Latino Y/SI No

$ ______________ Start date/ Fecha de Inicio

Second Parent in Household/Segundo Padre de la Casa N/A Check N/A If Second Parent is NOT Part of the Household/ Marque N/A Si Segundo Padre NO es Parte de la Casa 2. Name of Second Parent in Household /Nombre del segundo padre que está en Social Security (optional) / Número Date of Birth / Fecha de casa de seguro social (opcional) nacimento

Home Phone # / Teléfono del hogar

Place of Employment/Lugar de Empleo

Work Phone #/ Teléfono del Trabajo Pay Frequency/Frecuencia de Pago Weekly

Bi-Weekly

Monthly Bi-Monthly Name of School or Training Institution/ Nombre de la escuela o Institución de formación

Cell Phone # / Teléfono celular

Self Employed/Autónomo(a)

Income before taxes / Ingresos antes de impuestos $ __________________________ School Schedule/Horario Escolar

Other Contact # w/Name and Relation / Teléfono alternativo, nombre y relación:

Hispanic/ Latino Y/SI No

Work Schedule/Horario de Trabajo

Hire Date/ Fecha Contratado

Other Income/Otros Ingresos

Hourly Pay Rate/ Salario por Hora

Tips:$_________ Bonus:$_________ Commission $__________ None Semester Hours/Hours Semestre

Applicant Signature / Firma Del Solicitante:__________________________________________________

$ ______________ Start date/ Fecha de Inicio

Date / Fecha:______________________

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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CHILD CARE ELIGIBILITY CERTIFICATION APPLICATION TWIST # N/A Check N/A If You Don’t Have a Second Employment / Marque N/A Si Usted No Tiene Segundo Empleo Place of Employment/Lugar de Empleo Self Employed/Autónomo(a) Work Schedule/Horario de Trabajo Work Phone #/ Teléfono del Trabajo Pay Frequency/Frecuencia de Pago Weekly Monthly

Bi-Weekly Bi-Monthly

Income before taxes / Ingresos antes de impuestos $ __________________________

Other Income/Otros Ingresos Tips:$_________ Bonus:$_________ Commission $__________

None

Hire Date/ Fecha Contratado Hourly Pay Rate/ Salario por Hora $ ______________

Additional Income List any other sources of income or assistance your family receives and the amounts. Gross income including: bonuses, tips, commission, incentives pensions, annuities, life insurance, retirement income, early 401K withdraws, lottery winnings of $600.00 or greater, taxable capital gains, dividends, interest, rental income, public assistance payments, income from estate and trust funds, unemployment compensation, compensation income, spousal maintenance or alimony, court settlements or judgments, social security benefits, incentives, child support, etc. must be included. Note: You will need to provide CCS documentation for all income and/or benefits received on this list. Source of Income/ Who Receives the Income/ Amount/ How Often Received/ Fuente de Ingreso Quien Recibe los Ingresos Cantida Frecuencia lo Recibe

Name(s) / Nombre(s)

Other Household Dependents / Otros Dependiente Del Hogar Social Security# Child Birth Date Relation Sex Ethnicity (optional) Care Fecha de Relación Sexo Raza Numero De Requiere Nacimiento Seguro Social cuidado? (opcional)

Child with Special Needs Es niño(a) con necesidades especiales?

SSI

3.

M

F

Y/SI

No

Y/SI

No

Y/SI No

4.

M

F

Y/SI

No

Y/SI

No

Y/SI No

5.

M

F

Y/SI

No

Y/SI

No

Y/SI No

6.

M

F

Y/SI

No

Y/SI

No

Y/SI No

7.

M

F

Y/SI

No

Y/SI

No

Y/SI No

Grade School Grado Escolar

Provider Information/Informacion del Proveedor Day Care Name: __________________________________________

DC License #:___________________

Phone Number:_______________________

Nombre de Proveedor

Numero de Licencia

Numero de Teléfono

I understand that: (1) a person who obtains or attempts to obtain, by fraudulent means, services to which the person is not entitled may be prosecuted under applicable state and federal laws; (2) I am entitled to be notified about my eligibility for services within 20 calendar days from the date of this application; (3) I, or my representative, may appeal denial, reduction, or termination of services; (4) services will be provided without regard to sex, race, creed, color, national origin, or disability; (5) the information on this application is confidential. By signing this form, I am applying for services from Workforce Solutions or their child care contractor. I give permission to Workforce Solutions or their child care contractor to contact a third party to verify income or family size, and use the social security numbers for identification of Social Security Benefits and income. All Information provided represents a complete and accurate statement of my family’s circumstances at the time of application. I agree to report any changes to this information within 10 business days of the change. I understand that social security numbers (SSN) are voluntary and not a requirement to receive child care services. Entiendo que (1)Personas que obtienen o que atentan obtener, por medio ilícito, servicios a personas que no califican pueden ser demandadas bajo las leyes federales y estatales; (2) Tengo el derecho de recibir notificación de mi elegibilidad de servicios dentro 20 días calendarios a partir de la fecha de esta aplicación; (3) Yo, o mi representante, pueden apelar el rechazo, reducción o terminación de servicios; (4) servicios serán dados independiente de raza, sexo, credo, color, nacionalidad, o incapacitación; (5) la información en esta aplicación es confidencial. Al firmar esta forma, estoy aplicando para los servicios de Workforce Solutions o el contratista de cuidado de niños. Le doy permiso a Workforce Solutions o al contratista de cuidado de niños que contacten a terceros para verificar ingresos o la cantidad en la unidad de familia, y el uso de los números sociales para identificar ingresos y beneficios de seguro social. Toda la información proporcionada representa una declaración completa y precisa de las circunstancias de mi familia en el momento de la solicitud. Estoy de acuerdo en reportar cualquier cambio a esta información dentro de 10 días hábiles posteriores al cambio. Entiendo que el número social es voluntariado y no es un requisito para recibir servicios de cuidado infantil.

Applicant Signature / Firma Del Solicitante: _________________________________________________

Date / Fecha: _______________

CCS Representative / Firma de Representante de CCS: ___________________________________________

Date / Fecha: ________________

Office Use Only: Eligibility Start Date_____________________ Eligibility End Date

___________________

Family Size: _____________ 85% SMI: _____________________ Total HH Income: _______________________

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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Child Care Services WAGE VERIFICATION FORM TWIST #_____________ To be completed by employee: Release of Information I, _______________________________, authorize the release of the following information to Workforce Solutions. I understand that additional information may be required from my employer and/or clients. Signature: _________________________________

SSN: (Optional) ________________________________

To be completed by Employer: Do you currently employ the individual named above? Yes No Employee’s Job Title: ___________________________ Duties: ___________________________________ Pay Frequency: Daily Weekly Bi-Weekly Semi-monthly Monthly Hourly rate of pay: $ _________ Number of hours worked per week: ____________________ How is employee paid? Cash Check Direct Deposit Other Income? Bonus/Incentive Tips Commission Is overtime offered: Frequently Rarely Never Work Schedule Please mark the days and times employee is scheduled to work each week. (Ex. 8am – 5pm) Days Monday Tuesday Wednesday Thursday Friday Saturday Sunday Times Comments: ________________________________________________________________________________ On the chart below, please list the employee’s wages for the last FOUR pay periods. Pay Date Pay Period Dates Hours Worked Gross Wages From: To: 1. $ 2. $ 3. $ 4. $ FOR NEW EMPLOYEES Business/Employer Name: Date Hired: Address: Date of First Paycheck: Phone #: FOR EMPLOYEES NO LONGER WITH THE COMPANY Employer Representative Name: Last Date of Employment: Title: Date Final Paycheck Received: Date: The information above pertains to the employee’s eligibility for Child Care Services and is subject to validation against state and federal databases, in-person interviews, and/or submittal of additional supporting documentation. I acknowledge that the information I have provided is true and correct. I understand that a person who provides false or incorrect information for someone to obtain or attempt to obtain, by fraudulent means, services to which the person is not entitled may be prosecuted under applicable state and federal laws. Subject to verify information provided. _______________________________________________ Employer Representative Signature For Office Use

___________________________ Date

Telephone verification completed by: _____________________________ Date: ______________________ Representative Name, Title: ____________________________________ Phone: _____________________ Comments: ________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Deductions Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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Complete Work Schedule Verification Form (To be completed by employer) Note to employer: Your employee is applying for or is currently receiving child care assistance with Workforce Solutions -Child Care Services. To determine eligibility, we must receive a detailed summary of working hours. Please complete the following information: Employee Name:

________________________________________________________________

TWIST #/SSN # (optional): _________________________

Phone #: ______________________

TO BE COMPLETED BY EMPLOYER: Company Name:

___________________________________________________________

Company Address:

___________________________________________________________ ___________________________________________________________

Please indicate the shift hours for the employee for each day listed (ex: Monday 9am-5pm):

Monday:

_________________

Friday:

_________________

Tuesday:

_________________

Saturday:

_________________

Wednesday:

_________________

Sunday:

_________________

Thursday:

_________________

Does this schedule vary? Yes No If yes, please explain in detail: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ SIGNATURE (MUST BE SIGNED BY EMPLOYER)

__________________________________________________________________________________________ Person Completing This Form (Please Print) Title & Phone# _________________________________________________________________________________________ Signature Date

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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WORKFORCE SOLUTIONS-CHILD CARE SERVICES SELF-EMPLOYMENT For the purpose of child care eligibility, parents will be considered to be self-employed if their wage records do not reflect at least one of the following deductions: Federal Income Tax withholdings, Social Security or Medicare taxes. The federal minimum hourly wage will be applied to the self-employment net income to determine the parent’s work hours. Acceptable Documentation for Verification of Self-Employment Status One of the following forms of documentation will be required for initial verification and at every recertification of established self-employment enterprises: 1. Federal income tax forms or quarterly income reports, such as:  Form 1040; or  Schedule C, F, or SE federal income tax returns for the most recent tax year; OR 2. One of the following documentations can be used to document the existence of the business:  Property titles, deeds, or rental agreement for the place of business;  Recent business bank, phone, utility, or insurance bill; or  Recent state sales tax return, AND The following documentation along with Attachment A-Business Income Statement will be required to determine income eligibility for child care services:

1. Documentation that provides information on the amount of income generated and the associated business expenses and contains:  Customer names and contact information (if available);  Dates and locations of services provided;  Amounts received; AND 2. Business expense receipts that substantiate the expenses to be deducted from the gross income, when applicable. INDEPENDENT CONTRACTOR In certain cases a parent may not be claiming “self-employment” but rather “independent contractor”. A parent who may claim to be “independent” is someone who submits:  Checks from a business or an individual that does not contain deductions The following documentation along with Attachment A-Business Income Statement will be required to determine income eligibility for child care services:      

Checks from the business/individual containing the amount paid – the check should have the name of the business/individual as well as made out to the name of the parent Copies of the checks from the business/individual that have been processed (i.e. cashed by the parent) to demonstrate actual pay Bank statement from the parent showing deposits in the amount of the checks paid Work Verification Form (Page 5) Invoices Work orders

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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  

Customer contracts Tax Records List of Customer Contact

PAID IN CASH The following documentation along with Attachment A-Business Income Statement will be required to determine income eligibility for child care services:  Receipts from the parent to the person/business showing the amount the parent was paid for the work = the receipt should show the name of the person/business whom the parent received the payment from, the work performed, the date of the payment and location where work was performed  Receipts for expenses the parent spent to perform the work - inclusive of expenses such as fuel costs, transportation, etc.  Wage Verification Form (Page 5)  Information on the Internet  Business Card  Ledger  County Registration EXPENSES Expenses are your costs of doing business. Examples of expenses are supplies, repairs, rent, utilities, seed, feed, business insurance, licenses, fees, payments on principal of loans for income-producing property, capital asset purchases (such as real property, equipment, machinery, and other durable goods and capital asset improvements), your social security contribution for people who worked for you, and labor (not salaries you pay yourself). If you claim labor costs, list each person and the amount you paid them. If you have any other kinds of business expenses, be sure to list them and the date they were paid. If you are in doubt, bring proof of the expense and ask your worker. WORK HOURS CCS families are required to work an average of 25 hours per week for a single- parent household, or a combined 50 hours per week for a 2-parent household. CCS staff will calculate the amount of hours worked per week based on the net monthly income, the net income will be divided by the current minimum wage hourly rate to determine eligibility. CHILD CARE VERIFICATION REVIEW PROCESS Child Care Services staff will review TWC and other state databases during all child care eligibility certifications. If discrepancies are identified during the review process, staff will continue with the intake certification; however, customers will be notified in writing that they are required to assist in resolving discrepancies identified. Customers will be allowed 15 calendar days to report necessary changes to the appropriate agency to resolve all discrepancies. If the customer does not report to the appropriate agency to resolve all discrepancies within 15 calendar days, the customer will be mailed a 15 day termination of child care services notice.

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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Attachment A: Business Income Statement

1. Name of Person Having Self-Employment Income Nombre de la persona que tiene ingresos de negocio propio___________________________________________________________ 2. Give the number of months covered by this income statement. Dé el número de meses que cubre esta declaración de ingresos................................................................... 3. Describe what you did to earn this money: Describa lo que hizo para ganarse este dinero: ______________________________________________________________________ 4. List your business income and expenses (IMPORTANT: Attach receipts, invoices, or other verifying papers). Anote los ingresos y gastos de su negocio (IMPORTANTE: adjunte recibos, facturas u otros comprobantes).

Date Fecha

Business EXPENSES GASTOS

Total Business Expenses ----->

Amount Cantidad

$

Date Fecha

Business INCOME INGRESOS

Total Business Income -------> Total Business Expenses -----> Adjusted Business Income --->

Amount Cantidad

$ $

The above information is true, correct, and complete to the best of my knowledge. I understand that giving false information to the CCS contractor may result in my childcare being reduced, denied, or terminated up to and including prosecution for fraud. Print Name

Date

Signature

TWIST ID Attach …… to verify self-employment/business ownership.

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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School or Training Schedule Verification Form (To be completed by School or Training Institution) Case Name: __________________________________

TWIST #/SSN (optional): ___________________

Student Name: ________________________________

Phone #: ________________________________

Note to training institution: Your student is applying for or is currently receiving child care assistance from Workforce Solutions – Child Care Services. To determine their eligibility, we must receive a detailed summary of the student’s class/training schedule and attach enrollment form. Please complete the following information: Training Institution Name: ____________________________________________________________________ Address: __________________________________________________________________________________ _________________________________________________________________________________________ Student’s Date of Enrollment: ________________________

Projected End Date: ___________________

Please indicate the student’s class schedule for each day listed (ex: Monday 9am – 5pm) Monday:

_________________

Friday:

_________________

Tuesday:

_________________

Saturday:

_________________

Wednesday:

_________________

Sunday:

_________________

Thursday:

_________________

Does individual attend school regularly, and are they working toward successful completion? If no, please explain (comment is optional):

Yes

No

__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ SIGNATURE (Must be signed by SCHOOL or TRAINING INSTITUTION)

__________________________________________________________________________________________________ Person completing this form (please print name) Title & Phone # __________________________________________________________________________________________________ Signature Date Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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IMPORTANT Child Support Information Eligibility requirements state that in order for you to be eligible for services, you must prove that you are actively seeking child support (formal or informal agreements) for all children living in your household under the age of 18. It will be your responsibility to provide verification of compliance with this requirement in order to be considered eligible for child care assistance. If you do not have an informal arrangement with the non-custodial parent(s), you must:  Locate the Office of the Attorney General nearest you or apply online at www.oag.state.tx.us. Verification of the application or payment history will be required by Child Care Services in order for services to be authorized or re-authorized.  Proof of Paternity  Copies of Birth Certificate  Acknowledgement of Paternity  Office of Attorney General-Form 1825  Informal Child Support Agreement Form  Copy of Child Support Interactive (print screens)  Copy of divorce decree of section on child support  Letter from attorney, judge, or courts on child support  Child Care Services - Exceptions to Parent Responsibility Agreement Requirements

Please attach your child support documentation here and return to Child Care Services.     

Acceptable documents: Form 1825 with Payment History Child Support Income Verification Form Payment Status Payment Record Child Support Interactive (CIN) Form

(Please attach all child support documentation for all children in household)

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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Child Support Interactive (CIN) Form To: Child Care Services Case where the absent parent is not included in the Birth Certificate will require a Form 1825 to be completed by the OAG office.

Custodial Parent: _______________________________________ Non-Custodial Parent: ___________________________________ Mutual Child (ren): __________________________________

DOB: _________________

__________________________________

DOB: _________________

__________________________________

DOB: _________________

By signing below I acknowledge that the attached Child Support Interactive Print Screen belongs to me and my children. I understand that a person who obtains or attempts to obtain, by fraudulent means, services to which a person is not entitled may be prosecuted under applicable state and federal laws.

__________________________________________________________________________________________ To: Child Care Services Case where the absent parent is not included in the Birth Certificate will require a Form 1825 to be completed by the OAG office.

Custodial Parent: _______________________________________ Non-Custodial Parent: ___________________________________ Mutual Child (ren): __________________________________

DOB: _________________

__________________________________

DOB: _________________

__________________________________

DOB: _________________

By signing below I acknowledge that the attached Child Support Interactive Print Screen belongs to me and my children. I understand that a person who obtains or attempts to obtain, by fraudulent means, services to which a person is not entitled may be prosecuted under applicable state and federal laws.

Parent Signature: ______________________________ Date: ________________ SSN/TWIST ID: ______________________________ CCS Specialist: _____________________

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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Parent Responsibility Agreement Informal Child Support Form Parent Name (Print Name Here)

Twist #

State law requires that any family receiving child care assistance comply with the Parent Responsibility Act. This Act includes receiving child support for each individual child in the household. Failure to comply with this requirement will result in termination of services. When to use this form: This form is to be used ONLY when there is an informal ongoing child support arrangement between the custodial and the absent parent(s); which paternity has been established, not filed with the Attorney General Office or Private child Support Agency. (i.e., not working with the Office of Attorney General). Informal: The absent parent is giving you support payments instead of paying through the Office of Attorney General. Who completes this form: This form is to be completed by the custodial parent and by the absent parent, who is NOT living in the household. IMPORTANT: if any children in the household have informal arrangements with different absent parents, a separate form must be completed with each absent parent. Please make copies of this form for each child’s absent parent to complete and sign. Child care assistance will be terminated or denied if we do not receive this documentation. Custodial Parent Name:

Phone Number:

Custodial Parent Physical Address: Absent Parent Name:

Phone Number:

Absent Parent Physical Address: City

State

Zip

SSN (optional)

I, the absent parent, hereby attest that I am the father to the children listed below and I provide child support payments to their custodial parent. Child Name (First and Last Name)

Total Child Support ($)

How Often Weekly, Bi-Weekly, or Monthly

__________________________________________________________________________________________________________ Custodial Parent Signature Date __________________________________________________________________________________________________________ Absent Parent’s Signature Date Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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PARENT ACKNOWLEDGEMENT OF RIGHTS AND RESPONSIBILITIES FOR CHILD CARE SERVICES Parent Name: _____________________________________

TWIST ID: _____________

Please read the information on this form carefully before you and your spouse (if applicable) sign and date. Contact your child care worker immediately if you have any questions regarding the information or requirements on this form. Please understand Child Care Services can end at any time if you become ineligible, your eligibility cannot be determined or funding has been exhausted. PARENT ENROLLMENT I understand the availability of child care services, the process for accessing those services, my rights and responsibilities, and the process to receive and continue the child care services. My spouse (if applicable) and I must:  Be in training, education or employment activities for at least 25 hours a week for a single family, and 50 hours a week for a two parent household.  Be within income guidelines for my family size.  Reside within Hidalgo, Willacy, & Starr County.  Sign, date and submit all required forms and documents to CCS at least 10 work days before my eligibility end date.  Report loss of employment within 10 calendar days of occurrence. I understand that I may be eligible for a 28 day job search activity once a year (October to September).  Select the child care arrangement that my family will be using. I was given information about types of child care; licensed, registered, relative and those with providers with quality ratings.(Not available to CPS referred parents) I understand the requirements of the child care facility, and  I will pay my parent share of cost (parent fee) to the provider at the first of each month or before services are rendered.  I will meet the enrollment requirements and policies of the child care facility unless the policies directly conflict with those of CCS.  I will report to Child Care Services within 3 business days, instances in which an attempt to record attendance in CCAA is denied or rejected and cannot be corrected at the provider site. And that failure to report such instances will result in an absence counted against my child’s attendance.  I will contact the provider or my child care specialist if my child is/will be absent for five (5) consecutive days & must ensure absences are recorded in CCAA. I understand a fifteen (15) day notification is not required, and child care will not continue, during an appeal if the care was terminated due to not making this contact.  I will provide information including health and immunization records, authorization to secure medical assistance, and parent contact information to be used in case of an emergency.  I will abide by the child care facilities business hours and pay charges incurred if I am late picking up my child.  I will report to Texas Department of Family & Protective Services Child Care licensing office any possible violation of licensing standards at the child care facility. If I need child care on any of the provider’s authorized CCS paid holidays, I will make and pay for my own arrangements.  I will make and pay for other child care arrangements when I am no longer eligible for child care services.  I understand childcare providers are prohibited from denying a child care referral based on the parent’s income status, receipt of public assistance or the child’s Texas Department of Family and Protective Services status.  I understand providers cannot charge fees to parents receiving child care services that are not charged to parents who are not receiving child care services.  I understand I am allowed no more than three provider transfers per year based on anniversary date. Transfers are effective on the first of the following month. Exception to the transfer limit and effective start date are allowed due to child safety issues, provider corrective action or other extenuating circumstances. I release the Workforce Solutions-Child Care Services Contractor, Lower Rio Grande Valley Workforce Development (LRGVWD) Board, and Texas Workforce Commission (TWC) from any responsibility for the quality of the child care services my child may receive from the facility of my choosing.

Parent Signature: __________________________________________ Date: ______________________ Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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PARENT RESPONSIBILITYAGREEMENT (PRA) (not applicable to TDFPS and Choices Referrals)

I understand that my spouse, if applicable, and I:  Must establish paternity for my child (ren) and obtain child support for my child (ren).  Must not use, sell or possess marijuana or a controlled substance, or abuse alcohol.  Must make sure that each family member younger than 18 years of age attends school regularly, unless the child has a high school diploma or a GED credential, or is specifically exempt from school attendance by Texas Education Code (25.086).  Understand that the statements listed above will be reviewed at certification and recertification.  Understand that failure of the parent or caretaker to comply with the provisions of this agreement may result in denial of child care services. PARENT SELF-DECLARATION I declare that, since I was last determined to be eligible to receive child care services, my spouse (if applicable) and I have: Note: If 2nd parent is not in the household, please check the N/A box. Parent Spouse (N/A) Used, sold, or possessed marijuana or other controlled substances Yes No Yes No If “yes,” I am currently participating in or have completed a drug rehabilitation program and have attached documentation from the program. Yes No Yes No I have abused alcohol. Yes No Yes No If “yes,” I am currently participating in or have completed an alcohol rehabilitation program and have attached documentation from the program. Yes No Yes No Spouse Signature (if applicable):__________________________________

Date: _______________________

PARENT SHARE OF COST (Parent Fee) (not applicable to TDFPS, Choices, and SNAP Referrals)

      

I shall report to CCS and pay other child care subsidy I receive from another agency to the child care provider. I understand that the parent fee amount is based on my gross monthly income, the number of household members, and the number of children I have enrolled in care. I shall pay my parent fee even if my child is absent or is not there for the full month. If I do not pay the parent fee amount specified on the CCS Case Summary Information Form timely, my child care services may be terminated. I shall pay the parent fee to my child care provider before services are provided. I also understand that my child care services will be discontinued on the third (3rd) late parent fee provider report within a six month period. I understand a mandatory waiting period of thirty (30) days will be required before I can reapply or be placed on the waiting list for child care assistance after my child’s enrollment has been denied, reduced, suspended or terminated for nonpayment of the parent fee. I understand parent fee changes due to a change in the family’s gross monthly income; the new parent fee will not be effective until the first calendar day of the following month. PARENT RIGHTS

I understand that I have the following rights:

    

To request a Temporary Medical Incapacitation up to 60 days for a medical leave if I submit medical documents from my employer verifying dates of absence from and return to work. To appeal a denial, reduction, or termination of services. Note: Does not apply to parents who have children in in-home CPS cases and did not request child care. To have my personal information used to determine eligibility kept confidential. To receive services without regard to race, sex, color, national origin, age, political beliefs, religion, or disability. To be notified in writing at least 15 calendar days before the denial, reduction, or termination of child care services.

Parent Signature: __________________________________________________________ Date:___________________ Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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PARENT AWARENESS I shall be in training, education or employment activities at least 25 hours a week for a (1) parent household or at least a combined 50 hours a week for a (2) parent household. I understand that failure to comply with all Child Care Services Requirements, failure to report changes in my case within 10 calendar days of occurrence, and/or failure to provide true and correct information in my case may result in possible criminal prosecution. My case may be referred to the Local Law Enforcement Office, District Attorney’s Office (DA) and/or Office of Investigation (OI) for potential prosecution. I will also be required to pay back 100% of the money that was paid to my provider during the period of ineligibility. I will report the following within 10 calendar days of when the change occurs:     

Attendance in training, in school, or if my job stops or falls below the required number of hours per week. Total amount of income changes, including raises, overtime, bonuses, incentive pay, commission, or an increase in child support or other non-employment income and/or benefits (such as TANF or SSI). Marriage, divorce or a change in the number of family members living with me. Receipt or the award of any child care funds from other public or private entities; or Other changes that may affect the child’s eligibility or parent share of cost for child care.

REPORTING FAMILY INCOME I understand that I must report the following income on the CCS Eligibility Certification Form and must report changes to any of these income sources within 10 calendar days of occurrence for purposes of determining eligibility and the parent share of cost: 

Total gross earnings.



Net income from self-employment



Pensions, annuities, life insurance, and retirement income, and early withdrawals from a 401(k) plan not rolled over within 60 days of withdrawal

   

Taxable capital gains, dividends, and interest Net rental income Public assistance payments Income from estate and trust funds

 

Unemployment insurance Worker’s compensation income, death benefit payments, and/or other disability payments Lottery payments of $600 or greater.

  

Spousal maintenance or alimony Child support Court-settlements or judgments; and



I understand a mandatory waiting period of thirty (30) days will be required before a parent can reapply or be placed on the waiting list for child care assistance after eligibility was terminated due to failure to report to the Child Care Contractor, within 10 calendar days of occurrence, any changes in the family’s circumstances that would render the family ineligible for subsidized care. I understand that the information I provide to Workforce Solutions-Child Care Services to determine my eligibility is subject to validation through cross-checks against state and federal databases; and that I may be asked to provide original documents and participate in face-to-face interviews to verify identity and eligibility for child care services. Failure to comply with this requirement will constitute a voluntary discontinue.

PARENT ELIGIBILITY END DATE I understand that in order to continue to receive child care services, I must provide all Child Care Services required forms and documents along with all household income information to Workforce Solutions- Child Care Services at least 10 work days before my eligibility redetermination end date or my child care may be terminated.

Parent Signature: __________________________________________________

Date: ______________________

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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APPEALS I understand that participating in Child Care Services grants me the right to file a complaint regarding my child care services. I will be provided with an opportunity for an informal resolution in an attempt to resolve the issue. If I am not satisfied with the informal resolution, a Board hearing may be scheduled. Appeals:  I understand I have the right to appeal denial, reduction, or termination of services. This does not apply to parents who have children in in-home CPS cases and did not request child care.  You have 14 calendar days from the mailing date of the determination letter of an adverse action, such as a termination of services, to file an appeal with Workforce Solutions –Lower Rio Grande Valley Workforce Development (LRGVWD) Board requesting a review.

 

Your appeal must be submitted in writing and include: Your name, mailing address, and phone number

    

A copy of the determination letter (if applicable), and A brief justification of your appeal request The Board will provide an opportunity for an informal resolution in an attempt to resolve the issue. If you are not satisfied with the informal resolution, a Board hearing will be scheduled. You have the right to have a representative during the informal resolution and at the Board hearing. Your representative may include an attorney (at your expense), friend, co-worker, or family member. If you choose to have a representative during the informal resolution and/or Board hearing, you must submit a written authorization.

I read and understand all the requirements stated above and all my questions have been answered.

Parent Signature: ________________________________________________ Date: ______________________

CCS Representative Signature: _____________________________________ Date: ______________________

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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PARENT AGREEMENT FOR USE OF THE Child Care Attendance Automation (CCAA) System This policy requires that parents understand and comply with the requirements to use the CCAA card to report daily attendance and absences. I agree to the following: 1. I will use my CCAA card daily to report my child’s attendance and absences. Attendance can be reported at a point of service (POS) machine or through an Interactive Voice Response (IVR) telephone system at my child care facility. 2. I understand that my child care services may be terminated if I do not use my CCAA card to record attendance. 3. I shall record attendance when dropping off and when picking up my child from my child care provider. 4. I shall report to my Child Care Specialist within 3 business days, instances in which mine or my secondary card holder’s attempt to record attendance in CCAA is denied or rejected and cannot be corrected at the provider site. I understand that failure to report such instances may result in an absence counted toward the maximum 45 paid absences per year. 5. I understand I can designate up to three (3) individuals who will assist me in dropping off or picking up my children from my provider, as secondary cardholders to report attendance and absences on my behalf. Note: Secondary cardholders must be at least sixteen (16) years old, unless the individual is the child’s parent. 6. I shall NOT assign the owner, director, or employee of the child care facility as a secondary cardholder. 7. I understand that giving my CCAA card or PIN to anyone including the child care provider is a CCAA Violation and my child care services may be terminated. 8. I shall inform my secondary cardholder of the CCAA requirements and I am responsible for any misuse of the attendance card by my secondary cardholder(s). 9. I shall contact my Child Care Specialist if I do not receive my CCAA card within 10 days of receiving child care assistance. 10. I shall contact my Child Care Specialist immediately if my CCAA card is lost, stolen, misplaced or damaged. 11. I agree to report misuse of the CCAA cards and PINs to Workforce Solutions – Child Care Services immediately. 12. I understand that my child care services may be terminated if I exceed 45 paid absences per anniversary year. These absences include vacation, illnesses and Z-Days (a Z-Day is defined as an authorized care day for which no activity was reported by the parent through the CCAA system). The forty-five days per year, begins on the enrollment or anniversary date. Note: Enrollment/anniversary dates are child-specific and may vary for each child in care. 13. My child will not be allowed to receive child care services or be placed on the wait list for thirty (30) days after his or her services have been terminated due to five consecutive absences without parent notification or if I exceed the 45 paid absences. Child Care Services will notify me when my child reaches 50%, and 75% of the allowed absences. 14. I may request a waiver to continue care if 25 out of 45 absences are due to illness or extenuating circumstances and I can provide CCS with verifiable documentation.

Parent Signature: ___________________________________________

Date: ______________________

Parent Print Name: _________________________________________

TWIST #/SSN(optional): _______________

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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PARENT AGREEMENT FOR USE OF THE Child Care Attendance Automation (CCAA) System To report attendance…you or your secondary cardholder must: 1. Swipe your card. 2. Key in your PIN and press Enter. Choose Attendance Type (1 = Check-in, 2 = Check-out, 3 = Previous Check-in, 4 = Previous Check-out) Note: Previous Check-in and Check-out allows you to “backdate” attendance for the current or previous day. When this feature is used for a previous Check-In, you must make sure to enter the correct date and time. If this is done incorrectly, your CCAA will lock out and you will not be able to swipe for five (5) days. These non-swipes will be counted as absences. Your childcare services will be discontinued when you reach 45 absences. 3. Key in the Child Number and press Enter. 4. Repeat for each child. When finished, press Enter again. To report absences… you or your secondary cardholder must: 1. Swipe your card. 2. Key in your PIN and press Enter. 3. Choose 5 = Absence Day. 4. Select Absence Type and press Enter. 5. If not a General Absence type, select a Specific Reason. 6. Key in the Child Number and press Enter (obtain child # in your case summary form) 7. Repeat for the next child. When finished, press Enter again. To report attendance and absences in homes or facilities where there is no POS device, you or your secondary cardholder must use the Interactive Voice Response (IVR): 1. Call 1-866-960-6496 from the provider’s phone. 2. Enter your card number. 3. Enter your PIN. 4. Follow the instructions. You or your secondary cardholders are responsible for making sure attendance is approved for the day by: 1. Checking the message on the POS machine or receipt after each swipe to see if it is approved.  If the response is denied you must inform your provider.  If the response is 'Store and Forward' (SAF), you must notify the provider that the transaction was SAF, and  The provider will check at the next transaction to see if transaction was successful. 2. If using an IVR, you must listen to the IVR message after each recorded attendance to confirm attendance is approved and follow the same steps above if denied. 3. If attendance is not approved through the POS or IVR for three (3) consecutive days, you will need to notify your CCS worker. Failure to report this may result in absences counted toward the maximum 45 paid absences. 4. To replace a lost, stolen, or damaged card, you must call CCS and report it immediately. Failure to do so will cause your child to accumulate absences. 5. To reset a PIN, you must call the Child Care Attendance Card Customer Service number (1-866-960-6496). 6. When you or your secondary cardholder first receives the CCAA card, please call 1-866-960-6496 to select a personal identification number (PIN). You will need to enter the 16-digit card number and the cardholder’s date of birth to establish the PIN. By signing below I acknowledge that I have read and understand my responsibilities as a Child Care Services customer. I understand that if I violate the CCAA requirements my child care services may be terminated and I may be prosecuted for fraud.

Parent Signature: ___________________________________________

Date: ________________

Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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Child Care Attendance Automation (CCAA) Primary and Secondary Cardholder Request Form As the parent/caretaker you may request up to 3 different cardholders in addition to you, the primary cardholder. Please complete this form and fax to your child care worker immediately if you have a change in card holder or if your card is lost or stolen. Additional cards will not be ordered or reissued if the information below is incomplete and the signature is missing. Parents/Caretakers and secondary cardholders must keep their CCAA cards and PIN in their possession. Sharing or leaving the CCAA card and PIN with anyone else including the child care provider is a violation of the CCAA Requirements and as a CCS customer, you and your provider may be subject to adverse action. Primary Card Holder Name: _________________________________

Phone #: _____________________

TWIST #/SSN(optional): ___________________________________ Do you have your CCAA Card?

Yes

No

Please complete the following section for current and new secondary cardholders. Note: If applicable, list ALL secondary cardholders and indicate if they already have a card or if they need a replacement card. Be aware that if you do not list your secondary cardholders below, their cards will be inactivated. Please ensure that this form is completely filled out. Secondary Card Holder #1:

Has Card

Needs Card

Name: ___________________________________________________

Gender:

Male

Female

Date of Birth: ________________________Relationship to you: _________________________________

Secondary Card Holder #2:

Has Card

Needs Card

Name: ___________________________________________________

Gender:

Male

Female

Date of Birth: ________________________Relationship to you: _________________________________

Secondary Card Holder #3:

Has Card

Needs Card

Name: ___________________________________________________

Gender:

Male

Female

Date of Birth: ________________________Relationship to you: _________________________________

Primary Card Holder Signature: _________________________________

Date: __________________

Primary Card Holder Mailing Address: _______________________________________________________ Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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SELF- ATTESTATION OF SCHOOL ATTENDANCE To Parent: Please complete this form and return to Child Care Services. Please do not forward to school. I understand that: (1) a person who obtains or attempts to obtain, by fraudulent means, services to which the person is not entitled may be prosecuted under applicable state and federal laws; (2) services will be provided without regard to sex, race, creed, color, national origin, or disability; By signing this form, I am applying or re-applying for services from Workforce Solutions Child Care Services. I give permission to Workforce Solutions Child Care Services to contact the school to verify my child’s school attendance. To parent/guardian: The parent responsibility agreement (PRA) requires that each parent/guardian shall ensure that each family member younger than 18 years of age attends school regularly, unless the child has a high school diploma or a GED credential or is specifically exempt from school attendance by Texas Education Code (25.086). Case name/Name of parent

TWIST ID.

Address

#1) Name of Child: _______________________________________Date of Birth :______________________Grade:___________ Is this child attending school regularly?

Yes

No

Name of school:________________________________________________________________________________________ School Address/Telephone number:_________________________________________________________________________ Hours child is in school (Ex: M-F, 8a-4p): ____________________________________________________________________

#2) Name of Child: _______________________________________Date of Birth :______________________Grade:___________ Is this child attending school regularly?

Yes

No

Name of school:________________________________________________________________________________________ School Address/Telephone number:_________________________________________________________________________ Hours child is in school (Ex: M-F, 8a-4p): ____________________________________________________________________

#3) Name of Child: _______________________________________Date of Birth :______________________Grade:___________ Is this child attending school regularly?

Yes

No

Name of school:________________________________________________________________________________________ School Address/Telephone number:_________________________________________________________________________ Hours child is in school (Ex: M-F, 8a-5p): ____________________________________________________________________

Parent Signature:_______________________________________________

Date: __________________

Parent Print Name: _____________________________________________ Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711 R 6.29.15

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LOWER RIO GRANDE VALLEY WORKFORCE DEVELOPMENT BOARD

FORMULARIO PARA LA ORIENTACIÓN A LOS PROCEDIMIENTOS DE QUEJA DE DISCRIMINACIÓN (29 CFR Part 38) Este Formulario para la Orientación a los Procedimientos de Queja de Discriminación explica los procedimientos de queja de discriminación para los programas y los servicios mencionados administrados en el Local Workforce Development Area por el Workforce Development Board y sus contratistas: Workforce Innovation and Opportunity Act (WOIA) Temporary Assistance for Needy Families (TANF) / CHOICES Supplemental Nutrition Assistance Program Employment & Training (SNAP E&T) Child Care Services (CC) Trade Adjustment Assistance (TAA) and Trade Readjustment Allowances (TRA) RECIPIENTE DEL APOYO FINANCIERO FEDERAL ES:

LRGV Workforce Development Board 3101 West Business 83 McAllen, TX 78501

Oficial de Igualdad de Oportunidades (EO): Robert Barbosa Número telefónico: (956) 928-5000 Relay Texas: 1-800-735-2989/ TTY 1-800-735-2988 (Voz)

El LRGV Workforce Development Board (el Board) resolverá quejas de la igualdad de oportunidades de una manera justa y expediente. Se prohiben los actos de internamiento, de interferencia, de la coerción, de la discriminación, o de la represalia hacia los denunciantes que ejercitan sus derechos de presentar una queja conforme a este procedimiento. Este procedimiento se aplica a todos los aspirantes y participantes que tengan causa para presentar una queja de la discriminación relacionada con las actividades o los programas administrados por el Board. Si tiene una queja de la igualdad de oportunidades referente a cualquiera de estos programas, puede presentar su queja oficial por escrito al Oficial de EO del Board o del contratista, como sea apropiado. Después de que se haya recibido su queja de la igualdad de oportunidades, el oficial del EO le notificará del paso siguiente en el proceso de la queja. Mientras desea perseguir su queja, el Board o el contratista seguirá los pasos descritos abajo. Debe estudiar el procedimiento de queja de la discriminación cuidadosamente, y si se siente que los pasos requeridos no se están siguiendo, póngase en contacto con el oficial del EO. Recuerde que si se siente que no le están proporcionando bastante ayuda en cualquier etapa del proceso de la queja, usted debe ponerse en contacto con: Texas Workforce Commission (TWC) Equal Opportunity Monitoring 101 E. 15th St., Room 242-T Austin, TX 78778-0001

Números telefónicos: 512-463-2400 Relay Texas: 1-800-735-2989 TTY 1-800-735-2988 (Voz)

LA IGUALDAD DE OPORTUNIDADES ES LA LEY El destinatario de asistencia financiera del Gobierno Federal tiene prohibido por ley discriminar, con base en los conceptos a continuación: discriminar a cualquier persona en los Estados Unidos por motivos de su raza, color, religión, sexo, origen nacional, edad, incapacitación, afiliación o ideología política; discriminar a cualquier beneficiario de programas que cuenten con apoyo financiero a tenor del Título I de la Acta Fuerza Laboral de Innovacion y Oportunidad (Workforce Innovation and Opportunity Act o WIOA), por motivo de la ciudadanía o calidad migratoria del beneficiario en tanto inmigrante legalmente autorizado para trabajar en los Estado Unidos; o por motivo de su participación en cualquier programa o actividad que cuente con apoyo financiero a tenor del Título I de la WIOA. El destinatario de tal asistencia no debe discriminar en ninguno de los conceptos a continuación: en decidir quiénes han de ser admitidos o tener acceso a cualquier programa o actividad que cuente con apoyo financiero a tenor del Título I de la WIOA; en la provisión de oportunidades en tal programa o actividad y en el trato a cualquier personal con respecto al programa o actividad; o en la toma de decisiones de empleo en la administración de tal programa o actividad o con respecto al mismo. Qué hacer si usted cree haber sido discriminado/a: Si cree haber sufrido discriminación en un programa o actividad con apoyo financiado a tenor del Título I de la WIA, puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el Director, Civil Rights Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, D.C. 20210. Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en la más temprana de las dos fechas) antes de presentar su queja al CRC). Si el destinatario de asistencia federal no le entrega un Aviso de Acción Definitiva por escrito dentro de los 90 días de la fecha de presentación de su queja, usted no tiene obligación de esperar a que el destinatario le expida dicho Aviso para presentar una queja con el CRC. Por otra parte, la queja con el CRC debe presentarse dentro de los 30 días del vencimiento del plazo de 90 días, es decir, dentro de 120 días a partir de la fecha en que presentó su queja con el destinatario. Si éste le entrega un Aviso de Acción Definitiva por escrito con respecto a su queja y usted sigue inconforme con la decisión o resolución, puede presentar una queja con el CRC. Hay que presentarla dentro de los 30 días subsiguientes a la fecha en que recibió el Aviso de Acción Definitiva.

INSTRUCCIONES DETALLADAS PARA CLASIFICAR UNA QUEJA

D WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) / TRADE ADJUSTMENT ASSISTANCE (TAA) y TRADE READJUSTMENT ALLOW ANCES (TRA): Si cree haber sufrido discriminación en un programa o actividad con apoyo financiero a tenor del Titulo I de la WIOA o TAA/TRA, puede presentar una queja dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el Director, Civil Rights Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, DC 20210. Si presenta su queja con el destinatario de asistencia federal o su contratista, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las dos fechas) antes de presentar su queja al CRC. Sí el destinatario de asistencia federal no le entrega un Aviso de Acción Definitiva por escrito dentro de los 90 días de la fecha de presentación de su queja, usted puede presentar una queja con el CRC. La queja CRC debe presentarse dentro de los 30 días del vencimiento del plazo de 90 días, es decir, dentro de 120 días a partir de la fecha en que presentó su queja con el destinatario. Si éste le entrega un Aviso de Acción Definitiva por escrito con respecto a su queja y usted sigue inconforme con la decisión o resolución, puede presentar una queja con el CRC. Hay que presentarla con el CRC dentro de los 30 días subsiguientes a la fecha en que recibió el Aviso de Acción Definitiva. D TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) / CHOICES and/or CHILD CARE SERVICES (CC): Si cree haber sufrido discriminación en un programa o actividad a tenor TANF/Choices y/o Child Care Services (CC) que recibe asistencia financiera federal, puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con la Office for Civil Rights, 1301 Young Street, Suite 1169, Dallas, TX 75202, (800) 368-1019. Si cree haber sufrido discriminación en un programa o actividad a tenor de la CC que recibe asistencia financiera federal de USDA, puede proponerse en contacto con el U.S. Department of Agriculture (USDA), Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410. Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las dos fechas) antes de presentar su queja al U.S. Dept. of Health and Human Services.

D SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM EMPLOYMENT AND TRAINING (SNAP E&T): Si cree haber sufrido discriminación en un programa o actividad con apoyo financiero a tenor del programa SNAP E&T, puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC 20250-9410 o llame al 202-260-1026. Si presenta su queja con el destinatario de asistencia federal o su contratista, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las dos fechas) antes de presentar su queja al U.S. Dept. of Agriculture. Favor de no firmar sin haber leído este aviso y haber comprendido su contenido. Por mi firma abajo, reconozco esta orientación al procedimiento de queja de la discriminación y la declaración con respecto a que la igualdad de oportunidades es la ley. Afirmo que he leído el Formulario para la Orientación a los Procedimientos de Queja de Discriminación y que me han dado la oportunidad de hacer preguntas acerca de su contenido. Entiendo que el formulario One-Stop no es solicitud para trabajo; se utiliza para determinar mi elegibilidad para recibir servicios de programa y para cumplir con requisitos federales de información. Entiendo también que la falta de proporcionar la información pedida puede evitar que reciba servicios.

Firma del solicitante

Nombre en letra de molde

Fecha

EMPLEADOR CON IGUALDAD DE OPORTUNIDAD EMPLEO/PROGRAMAS Auxiliary aids and services are available upon request to individuals with disabilities. Relay DE Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711

R 6.29.15

Ayudas auxiliares y servicios están disponibles a petición para individuos con incapacidades Relay Texas: 1-800-735-2989 (TTY); 1-800-735-2988 (Voz); 1-800-622-4954 (Español)

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LOWER RIO GRANDE VALLEY WORKFORCE DEVELOPMENT BOARD

ORIENTATION TO DISCRIMINATION COMPLAINT PROCEDURES FORM (29 CFR Part 38) This Orientation to Discrimination Complaint Procedures Form addresses discrimination complaint procedures for the listed programs and services administered in the local workforce development area by the Workforce Development Board and its Contractors:

Workforce Innovation and Opportunity Act (WIOA) Temporary Assistance for Needy Families (TANF) / CHOICES Supplemental Nutrition Assistance Program Employment & Training (SNAP E&T) Child Care Services (CC) Trade Adjustment Assistance (TAA) and Trade Readjustment Allowances (TRA) THE RECIPIENT OF THE FEDERAL FINANCIAL ASSISTANCE IS:

LRGV Workforce Development Board 3101 West Business 83 McAllen, TX 78501

Equal Opportunity (EO) Officer: Robert Barbosa Telephone Number: (956) 928-5000 Relay Texas: 1-800-735-2989/ TTY 1-800-735-2988 (Voice)

The LRGV Workforce Development Board (the Board) shall resolve equal opportunity complaints in a fair and prompt manner. Acts of restraint, interference, coercion, discrimination, or reprisal towards complainants exercising their rights to file a complaint under this procedure are prohibited. This procedure applies to all applicants and participants who have cause to file a discrimination complaint related to activities or programs administered by the Board. If you have an equal opportunity complaint concerning any of these programs, you may submit your written complaint to the Board or Contractor EO Officer, as appropriate. After your equal opportunity complaint has been received, the EO Officer will notify you of the next step in the complaint process. As long as you wish to pursue your complaint, the Board or Contractor will follow the steps described below. You should study the Discrimination Complaint Procedure carefully, and if you feel that the required steps are not being followed, contact the EO Officer. Remember, if you feel you are not being provided enough help at any stage of the complaint process, you should contact:

Texas Workforce Commission (TWC) Equal Opportunity Monitoring 101 E. 15th St., Room 242-T Austin, TX 78778-0001

Telephone Numbers: (512) 463-2400 Relay Texas: 1-800-735-2989 TTY 1-800-735-2988 (Voice) EQUAL OPPORTUNITY IS THE LAW

It is against the law for this recipient of Federal financial assistance to discriminate on the following bases: against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of programs financially assisted under Title I of the Workforce Innovation and Opportunity Act (WIOA), on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIOA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following areas: deciding who will be admitted, or have access, to any WIOA Title I-financially assisted program or activity; providing opportunities in, or treating any person with regard to, such a program or activity; or making employment decisions in the administration of, or in connection with, such a program or activity.

What to do if you believe you have experienced discrimination. If you think that you have been subjected to discrimination under a WIOA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: the recipient’s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or the Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, DC 20210. If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.

PROCEDURES ON HOW TO FILE A COMPLAINT D WORKFORCE INVESTMENT ACT (WIA) / TRADE ADJUSTMENT ASSISTANCE (TAA) and TRADE READJUSTMENT ALLOW ANCES (TRA): If you think you have been subjected to equal opportunity discrimination under a WIA Title I or a TAA/TRA financially assisted program or activity, you may file a discrimination complaint within 180 days from the date of the alleged violation with either the Board/Contractor Equal Opportunity Officer (or designee) or Director, Civil Rights Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N-4123 Washington, DC 20210. If you file your complaint with the Board or Contractor, you must wait until you receive a written Notice of Final Action or 90 days have passed (whichever is sooner) before you can file with the CRC. If the written Notice of Final Action is not issued within 90 days of the day you filed your complaint, you have 30 days following the 90-day deadline to file a complaint with CRC (that is, within 120 days of the day you first filed your complaint). If you receive a written Notice of Final Action on your complaint but are dissatisfied with the decision, you may file a complaint with CRC. However, you must file your CRC complaint within 30 days of receiving the Notice of Final Action.

D TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) / CHOICES and/or CHILD CARE SERVICES (CC): If you think you have been subjected to equal opportunity discrimination under a TANF/Choices and/or Child Care Services (CC) financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either the Board/Contractor Equal Opportunity Officer (or designee) or the Office of Civil Rights, U.S Department of Health and Human Services (HHS), 1301 Young Street, Suite 1169, Dallas, TX 75202, (214) 767-4056. Those filing complaints on child care services may choose to contact the U.S. Department of Agriculture (USDA), Office of Civil Rights-Southwest Region, Food and Nutrition Services, 1100 Commerce Street, Room 555, Dallas, Texas 75242, (214) 290-9837. If you file your complaint with the Board or Contractor, you must wait until a written Notice of Final Action is issued or until 90 days have passed (whichever is sooner) before you can file with the U.S. Department of Health and Human Services.

D SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM EMPLOYMENT AND TRAINING (SNAP E&T): If you think you have been subjected to discrimination under a SNAP E&T financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either the Board/Contractor Equal Opportunity Officer (or designee) or the U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC 20250-9410, (202) 260-1026. If you file your complaint with the Board or Contractor, you must wait either until a written Notice of Final Action is issued or until 90 days have passed (whichever is sooner) before filing with the U.S. Department of Agriculture.

Please do not sign this notice until you have read it and understand its contents. By my signature below, I acknowledge this orientation to the discrimination complaint procedure and the statement regarding Equal Opportunity Is the Law. I affirm that I have read the Orientation to Discrimination Complaint Procedure Form and that I have been given the opportunity to ask questions about its contents. I understand that the One-Stop application form is not a job application; rather, it is used to determine my eligibility to receive program services and to meet federal reporting requirements. I further understand that failure to provide the requested information may prevent me from receiving services.

Applicant Signature

Printed Name

Date

ANtoEQUAL OPPORTUNITY EMPLOYER / PROGRAM Auxiliary aids and services are available upon request individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711

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Auxiliary aids and services are available upon request to individuals with disabilities Relay Texas: 1-800-735-2989 (TTY); 1-800-735-2988 (Voice); 1-800-622-4954 (Español)

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