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Revised: 9/25/2020 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Office of Child Care & Regulatory Services COVID-19 INFORMAL PROVIDER/FFN Parent Applicant Thank you for your interest in the Family, Friends, and Neighbor program. The following documents are required from all applicants. 1. Proof of Citizenship/U.S. Residency (e.g. Birth Certificate, or U.S. Passport, or Permanent Resident Card) 2. Government Issued Picture I.D. (e.g. Driver’s License, or U.S. Passport, or Permanent Resident Card, or V.I. Voter’s Registration Card) 3. If married, or living together, both incomes must be submitted. Parent Information Parent(s) Name: ________________________________ Contact Number:________________ ____ Married ____ Single Mailing Address: ______________________________________________________________ Email Address: ________________________________________________________________ Physical Address: ______________________________________________________________ Place of Employment: __________________________________________________________ Employer’s Mailing Address: ____________________________________________________ _____________________________________________________ Employer’s Telephone Number: __________________________________________________ Employment Status: Permanent________ Part-time_________ Temporary _______ □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 & 2138 Fax: (340)773-6121 □ 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 & 4186 Fax: (340)774-4673 Revised: 9/25/2020 Informal Provider/FFN Information FFN Provider Name:_____________________________________________________________ Physical Address:_______________________________________________________________ Mailing Address:________________________________________________________________ Email Address:_________________________________________________________________ Relationship: _________________________________________________________________ (Family, Friend, or Neighbor) Home Phone: ____________________ Cell Phone: _________________________ Child(ren) Information Required Documents for Child(ren): 1. Birth Certificate(s) 2. If the Applicant is Guardian- Legal Court Order or other Legal Document Naming Applicant as Guardian 3. Immunization Card(s) or Exempt Letter (child/ren receiving assistance) 4. Social Security Cards Married applicants not living with their spouses must submit a notarized letter stating this fact, in addition to proof of child support. Applicants receiving assistance through Paternity and Child Support must have current documents (updated status of the case). However, parents who are not receiving support for their child/ren; must establish a case at Paternity and Child Support. Does the Child(ren) have a disability? Yes ________ No_________ Note: If a child or children has disabilities or special needs care, increased child care subsidies/assistance is possible Revised: 9/25/2020 PARENT CHILD CARE SUBSIDY AWARD Date: NOTICE is hereby provided that: I have 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 to 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 parents/guardians accept 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 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. Revised: 9/25/2020 I authorize DHS to make payments for child care services to the following DHS approved Informal Provider/FFN child care provider of my choice: Informal Provider/ FFN Name: __________________________________________________ Informal Provider/FFN Mailing Address: _________________________________________ ERP Vendor Number: ___________________________________________________ (To Be Filled in by DHS Staff) 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. I am responsible for paying 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 exceed the maximum subsidy indicated in this Parent-Child Care Subsidy Award. 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. Child’s Name FFN Rate Subsidy Fee Co-Payment Difference between Provider’s rate and subsidy to be paid by Parent/Guardian Total Revised: 9/25/2020 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 ten (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. 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 _____________ 2020 By: ___________________________________ Kimberley Causey-Gomez Commissioner Revised: 9/25/2020 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) We understand and accept all of the terms that I am required to comply with while receiving child care 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 We 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