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CASE NAME: CASE NUMBER: LOCATION: ELIGIBILITY PERIOD BEGINNING DATE: ENDING DATE: PARENT CHILD CARE SUBSIDY AWARD February 6, 2020 NOTICE is hereby provided that: has been awarded child care assistance in the form of a voucher for child care services under the Virgin Islands Department of Human Services (“DHS”) Subsidy, Resource & Referral Program (also referred to in this document as “Child Care Subsidy”). This Award is to assist eligible families with the cost of licensed child care or Family, Friends or Neighbors (FFN) approved care for children ages 0 to 12 years. To be eligible for child care financial subsidies, families are required to agree and follow the terms outlined in this Parent Child Care Subsidy Award along with the policies of the Virgin Islands licensed Child Care Provider/Center selected by the parents. By signing below, the parent/guardian accepts the terms and conditions of this Subsidy Award. I. PROGRAM REQUIREMENTS A. Reason for Child Care Subsidy Parents/Guardians are determined to be eligible for Child Care Subsidy Awards based on one or more of the following criteria: (1) Working (part-time or full-time); (2) Going to school or a training program (part-time or full-time); (3) One or both parents/guardians have an illness, disability or exceptional circumstance verified by a physician or other relevant professional; and/or, (4) The child(ren) have social or special needs requirements. B. Annual Assessment Parent Subsidy Award Letter Page: 2 Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 773-2323 phone • (340) 718-9763 fax I understand that the Subsidy my child/children are eligible to receive is based on (1) my income, (2) family size, and (3) type of child care provider I select to care for my child(ren). The amount of subsidy is based on the current maximum rates established by the DHS Subsidy, Resource & Referral Program. I understand that I will be notified of any changes to these amounts. I understand that I am eligible to receive child care vouchers for each child for a period of 12 months or less. I also understand that my eligibility will be assessed every twelve (12) months. If I do not keep my scheduled recertification appointments, provide proof of continued eligibility, notify my child care provider and the DHS Subsidy, Resource & Referral Program of any child care changes within the period of service, and failure to submit requested documents may result in the termination of this Child Care Subsidy Award. I authorize DHS to make payments for child care services to the following DHS approved licensed or registered child care provider of my choice: Center Name: Center Address: DHS License Number: Vendor Number: I understand that if at any time the child care provider identified above is no longer caring for my child(ren), they will immediately notify DHS Subsidy, Resource & Referral Program of this change and payments will be discontinued. C. Subsidy Payment The vouchers will be printed in the name of the Child Care Provider for my child(ren) and in the amount of each child’s eligibility. I understand the child’s parent(s)/guardian(s) will not be paid as caregivers for their own child(ren). In addition, the Subsidy, Resource & Referral Program will not provide payments to Informal Providers who reside in the same household with the parent(s)/guardian(s) and child(ren). An Informal Provider is a Family, Friend or Neighbor (FFN) who provides care for children in their own home or in home of the parents/guardians, and they must be registered with the Office of Child Care and Regulatory Services. Parent Subsidy Award Letter Page: 3 Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 773-2323 phone • (340) 718-9763 fax I am responsible to pay the established co-payment (cost sharing) fees each month, per child to the Child Care Provider. Furthermore, I understand that as the parent/guardian I will also be responsible for any other child care provider costs that exceeds the maximum subsidy indicated in this Parent Child Care Subsidy Award. I understand and agree that based on availability of funds, I will be eligible for the following child care subsidies per child and will be responsible for co-payments and differences: Child [initials & last 4 digits of SSN] SSN Provider’s Rate Subsidy Co-Payment Difference between Provider’s rate and subsidy to be paid by Parent/Guardian Total $0 $0 $0 $0 $0 Child [initials & last 4 digits of SSN] SSN Provider’s Rate Subsidy Co-Payment Difference between Provider’s rate and subsidy to be paid by Parent/Guardian Total $0 $0 $0 $0 $0 I understand that this subsidy and any future child care assistance pursuant to this Award, for which I may be eligible, is contingent on the availability of federal funds. I understand that notification must be provided to the DHS Subsidy, Resource & Referral Program of any changes in my family circumstances within ten (10) business days of the occurrence. It is understood that failure to report income increases within 10 business days may result in an overpayment in subsidies, and that if an overpayment occurs, the subsidized amount will be adjusted the following month. I understand that the DHS Subsidy, Resource & Referral Program is authorized to issue vouchers to only one provider for a specific period. However, I may choose a different provider to care for my child within the period of eligibility, it is understood and agreed that there will be no overlapping and double payments to providers for the same dates of care. Parent Subsidy Award Letter Page: 4 Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 773-2323 phone • (340) 718-9763 fax I read this Agreement, understand and accept the terms. I also understand that failure to comply with the terms of this Parent Child Care Subsidy Award may result in delay, suspension or termination of my child care assistance. II. APPEAL PROCESS I received a copy of this Parent Child Care Subsidy Award and understand that if I disagree with a decision that affects my Parent Child Care Subsidy Award that I have the right to appeal and request a Fair Hearing by providing a written request to the Commissioner of the Department of Human Services. DONE this _____ day of _____________ 2022 By: ___________________________________ Kimberley Causey-Gomez Commissioner Parent Subsidy Award Letter Page: 5 Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 773-2323 phone • (340) 718-9763 fax ACCEPTANCE OF AWARD BY PARENT(S)/GUARDIAN(S) By applying for Child Care Fee Subsidy, and signing this Parent Child Care Subsidy Award, we acknowledge and agree that: (a) I understand and accept all of the terms that I am required to comply with while receiving child care fee subsidies; (b) Child care fee subsidy is being provided to you on behalf of your child(ren) on the condition that you comply with these terms; and, (c) That my failure to comply with these terms could result in termination of the subsidy and I will have to repay any subsidy issued for which I am not eligible, and this may result in legal action. Date: ___________________________ ____________________________________________ APPLICANT: Signature of Parent(s)/Guardians Date: ___________________________ ____________________________________________ APPLICANT: Signature of Parent(s)/Guardians