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1 Revised October 2012 VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES Office of Child Care & Regulatory Services Subsidy, Resource & Referral Program (SR&R) Policies and Procedures Manual 2 Revised October 2012 POLICIES AND PROCEDURES MANUAL Department of Human Services Subsidy, Resource & Referral Program TABLE OF CONTENTS Section 1 MANUAL PURPOSE ................................................................................... 6 Section 2 BACKGROUND ........................................................................................... 7 Section 3 GOALS AND OBJECTIVES ...................................................................... 8 3:1 GOAL ...................................................................................................... 8 3:2 OBJECTIVES .......................................................................................... 8 Section 4 RESTRICTION OF FUNDS ........................................................................ 9 Section 5 ORGANIZATIONAL CHART FOR OCCRS ......................................... 10 Section 6 ACRONYMS ............................................................................................... 11 Section 7 KEY CONTACTS ....................................................................................... 12 7:1 FEDERAL -Region II…………………………...……………………..12 7:2 LOCAL - Territory ............................................................................... 13 Section 8 PROGRAM DEVELOPMENT ................................................................. 14 Section 9 PROGRAM MONITORING ..................................................................... 15 Section 10 PERSONNEL ADMINISTRATION ......................................................... 16 Section 11 PROGRAM DIRECTOR ........................................................................... 17 11:1 RESPONSIBILITIES ............................................................................. 17 11:2 STAFF .................................................................................................... 17 Section 12 CHILD CARE SPECIALIST .................................................................... 18 12:1 AVAILABLE SLOT .............................................................................. 18 12:2 ELIGIBILITY DETERMINATIONS .................................................... 18 12:3 DOCUMENT REQUIREMENTS .......................................................... 18 12:3-A INCOME ............................................................................................ 18 12:3-B SCHOOL, TRAINING/VOLUNTEER ............................................. 19 12:3-D SPECIAL NEEDS ............................................................................. 20 12:3-E FOSTER, PROTECTIVE & INTAKE SERVICES .......................... 21 12:3-F CHILD SUPPORT ............................................................................. 21 12:4 APPLICATION PROCESS .................................................................... 22 3 Revised October 2012 12:5 CHANGING PROVIDER ...................................................................... 22 12:6 DETERMINING SUBSIDY AMOUNT ................................................ 22 12:7 INELIGIBILITY .................................................................................... 23 12:8 RECERTIFICATION ............................................................................. 23 12:9 REPORTS ............................................................................................... 23 Section 13 CASE FILE MANAGEMENT .................................................................. 24 13:1 GENERAL CASE FILE INFORMATION ............................................ 24 13:2 CASE FILE ACCESS ............................................................................ 24 13:3 CASE FILE CONTENTS ....................................................................... 25 13:4 CASE FILE EXCHANGE...................................................................... 25 13:5 CASE FILE ORDER .............................................................................. 25 13:6 CASE FILE RETENTION ..................................................................... 27 13:7 CASE FILE TRANSFERS ..................................................................... 27 13:8 CASE FILE TRANSITION.................................................................... 27 Section 14 WAITING LIST ......................................................................................... 32 14:1 GENERAL WAITING LIST INFORMATION ..................................... 26 14:2 CREATION OF WAITING LIST .......................................................... 26 14:3 PRELIMINARY ELIGIBILITY ............................................................ 27 14:4 PRIORITIZATION OF SERVICE NEED ............................................. 28 14:5 WAITING LIST MAINTENANCE ....................................................... 28 14:6 WAITING LIST PROCESS ................................................................... 29 Section 15 PROCESSING COORDINATOR ............................................................. 29 15:1 LICENSE PROVIDER ........................................................................... 29 15:2 INFORMAL PROVIDER ....................................................................... 30 15:3 PROVIDER DOCUMENTS ................................................................... 30 15:4 VOUCHER PREPARATION ................................................................. 32 15:5 VOUCHER DISTRIBUTION ................................................................. 32 15:6 VOUCHER BASED ON ATTENDANCE ............................................. 32 15:7 VOUCHER ADJUSTMENTS………………………………………….32 15:8 VOUCHER VOIDING……………………………….………………...33 15:9 VOUCHER REPLACEMENT…………………………………………33 15:10 VOUCHER APPOINTMENT CARE REPLACEMENT…………...…33 15:11 VOUCHER PROCESSING……………………………………………34 15:12 PROCESSING REQUIREMENTS………………………………….…34 15:13 PROVIDER FILES………………………………...…………………...35 15:14 RECONCILIATION……………………………………………………35 15:15 REPORTS……………………...……………………………………….36 Section 16 GENERAL INFORMATION .................................................................... 39 16:1 AGE DISALLOWANCE/DISCOUNTINUANCE ................................. 39 16:2 APPEAL .................................................................................................. 39 16:3 APPOINTMENTS ................................................................................... 40 16:4 COMBINATION OF CARE & FEES……….…...…………….…….... 37 4 Revised October 2012 16:5 COMPLAINT PROCEDURES ............................................................... 41 16:6 COMPLEXITIES .................................................................................... 41 16:7 CONSUMER EDUCATION & INFORMATION.................................. 42 16:8 CONFLICTS OF INTEREST .................................................................. 42 16:9 CO-PAYMENTS & OUTSTANDING BALANCES ............................. 43 16:10 DISCOUNTS ........................................................................................... 43 16:11 FAILURE TO REPORT CHANGES ...................................................... 43 16:12 GRACE PERIODS .................................................................................. 43 16:13 INACTIVE CASES ................................................................................. 41 16:14 LIST GENERATION .............................................................................. 44 16:15 MAXIMUM ALLOWABLE FEES ......................................................... 42 16:16 PROVIDER CARE TYPES .................................................................... 42 16:17 PROVIDER CHOICES ........................................................................... 46 16:18 PROVIDER COMBINATIONS.............................................................. 47 16:19 PROXY .................................................................................................... 47 16:20 REAPPLY ............................................................................................... 48 16:21 RELEASE OF INFORMATION............................................................. 48 16:22 SECURITY MEASURES………………………………………………45 16:23 SUMMER ONLY………………………………………………...……..45 Section 17 ALTERNATIVE MEASURES .................................................................. 50 17:1 ALTERNATIVE TO PROCESSING APPLICATION .......................... 50 17:2 ALTERNATIVES TO PRINTING & PROCESSING VOUCHERS .... 50 17:3 ALTERNATIVES TO VOIDING VOUCHERS .................................... 50 17:4 SYSTEM FAILURE OR POWER OUTAGES ...................................... 51 Section 18 PROGRAM INTEGRITY.......................................................................... 52 18:1 IMPROPER PAYMENTS ....................................................................... 52 18:2 PROGRAM VIOLATIONS .................................................................... 52 18:3 ERRORS .................................................................................................. 52 18:4 RESPONSIBILITIES OF DIVISION STAFF ........................................ 53 18:5 IMPROPER PAYMENT REFERRAL DOCUMENTATION ........ 53 18:6 IMPROPER PAYMENT REFERRAL PROCESSING .......................... 53 18:7 FRAUD .................................................................................................... 53 18:8 INTERNAL AUDITS.............................................................................. 55 18:9 REPAYMENT ......................................................................................... 55 18:10 INTENTIONAL PROGRAM VIOLATIONS ........................................ 56 18:11 LEGAL ACTION .................................................................................... 56 18:12 COLLECTIONS METHODS .................................................................. 57 18:13 DISQUALIFICATION ............................................................................ 57 Section 19 DEFINITIONS ....................................................................................... 54-58 Section 20 REVISED SLIDING FEE SCALE…………...………………………….63 5 Revised October 2012 Section 21 FORMS & LETTERS ................................................................................ 65 21:1 STAFF LETTERS & FORMS ........................................................... 65-74 21:2 CLIENT LETTER & FORMS ......................................................... 75-105 21:3 PROVIDER LETTERS & FORMS ............................................... 104-128 21:4 OTHER LETTERS & FORMS ...................................................... 129-132 Section 22 APPENDIX ......................................................................................... 133-147 6 Revised October 2012 SECTION 1 MANUAL PURPOSE The purpose of this manual is to:  Increase the availability, affordability, and quality of child care services;  Provide low income families with the financial resources to locate and afford quality child care for their children;  Enhance the quality and increase the supply of child care for all families, including those who receive no direct assistance under the CCDF;  Promote parental choice to empower working parents to make their own decisions on the child care that best suits their family’s needs;  Strengthen the role of the family;  Improve the quality of and coordination among child care programs and early childhood development programs; and  Increase the availability of early childhood development with program that focus on before – and after-school-age care. 7 Revised October 2012 SECTION 2 BACKGROUND The Omnibus Budget Reconciliation Act of 1990 passed by Congress established the Child Care and Development Block Grant program. The program was a part of the legislation which was intended to provide child care for low income working families in need of child care and at risk of becoming eligible for Aid to Families with Dependent Children (AFDC) now known as Temporary Assistance for Needy Families (TANF). The Department of Health and Human Services, Administration for Children and Families is responsible for addressing the child care needs of low income working families. One of the programs which address those needs is the Child Care and Development Block Grant Program. The Final Rule published Tuesday, August 4, 1992 in the federal register volume 57, Part II Department of Health and Human Services “Child Care and Development Block Grant Act of 1990” (the act). The purpose of the Block Grant is to increase the availability, affordability, and quality of child care. The current CCBGG program evolved from changes implemented by PRWORA 1996, which incorporate the CCDBG and Title IV child care programs into the Child Care and Development Fund. ACF published the final rule in 1998 (Vol. 63, No. 142/Friday, July 24, 1998). The Virgin Islands Government, Department of Human Services applied for the funding and received the grant effective October 1, 1991. The program was placed under the Division of Volunteers and Special Programs and staff was hired and commenced operations on August 17, 1992. Subsequently, the Office of Child Care & Regulatory Services was given the responsibility to oversee the eligibility determination and processing of payments. Initially, the fiscal operation was paid through the Lutheran Social Services of the U.S. Virgin Islands from 1992 - 2004. Subsequently, the fiscal operation was transferred through the agencies (DHS), business office on St. Thomas effective October 2004. Finally, the program’s payment process transitioned via the Virgin Islands Government Financial System referred to as Enterprise Resource Planning (ERP) system through the Department of Finance, effective July 2011 to current. Effective December 2013, the Child Care Subsidy Program changed its program name to Subsidy, Resource and Referral Program, which overall goal is to promote quality child care in the territory by effective outreach, to provide valuable information and referral to our families and providers. 8 Revised October 2012 SECTION 3 GOALS AND OBJECTIVES Outline policies, procedures, and guidelines in an effort to provide eligibility services to prospective and continuing participants, in a consistent and efficient manner. 3:1 GOAL To enable eligible (low income, TANF, teen parent, children in protective custody) families receive child care of their choice from available licensed or registered providers who are in compliance with the Virgin Islands Department of Human Services, Office of Child Care & Regulatory Services Rules & Regulations. 3:2 OBJECTIVES 1. To recruit families by educating and advertising within the Virgin Islands. 2. To ensure that the type of care (center-based) meets licensing or (home-based) basic health and safety requirements. 3. To provide parents with consumer education information to assist parent in making informed child care choices on how to select child care and provide a list of licensed providers. 4. To assist parents obtain child care while they are trying to achieve independence from public assistance. 5. To provide technical assistance and training for providers who are licensed or registered. 6. To assist licensed or registered providers with program improvement efforts, on issues such as health, safety, licensing and established registration standards. 7. To establish a voucher program to assist eligible families pay for the cost of child care. 9 Revised October 2012 SECTION 4 RESTRICTION OF FUNDS The Child Care funds cannot be used by clients or providers for the following:  Children residing outside of the V.I. Territory.  Co-payments  Tuition payment for students ages 5years through 13 years enrolled in kindergarten through twelfth grade.  Field trips  School insurance  Late fees payment  Medical evaluations  Outstanding payment  Registration fee  School Supplies  T-shirts or uniforms  Unlicensed facilities or unregistered at-home provider. 10 Revised October 2012 SECTION 5 OFFICE OF CHILD CARE & REGULATORY SERVICES ORGANIZATIONAL CHART FOR OCCRS Director of Subsidy Director of Quality Assistant Commissioner Admin Support St. Croix Administrator Admin Support St. Thomas Quality Unit Education Specialist Quality Improvement Specialist – STT/STX Licensing Unit Licensing Specialist – STT/STX Senior Regulatory Specialist STX Subsidy, Resource & Referral Unit Child Care Specialist STT/STX Processing Specialist STT/STX Director of Licensing 11 Revised October 2012 SECTION 6 ACRONYMS ACF Administration for Children and Families AFDC Aid to Families with Dependent Children CCDF Child Care and Development Fund CYF Children, Youth & Families DHHS Department of Health and Human Services DHS Department of Human Services ERP Enterprise Resource Planning FFN Family, Friends & Neighbors JOBS Job Opportunity and Basic Skills QRIS Quality Rating Improvement Systems MIS Management Information Systems OIES Office of Intake & Emergency Services OCCRS Office of Child Care & Regulatory Services TANF Temporary Assistance to Needy Families SNAP Supplemental Nutrition Assistance Program SRR Subsidy, Resource & Referral Program 12 Revised October 2012 SECTION 7 KEY CONTACTS 7:1 FEDERAL - (Region II) Office of Child Care Administration for Children and Families U.S. Department of Health and Human Services Aerospace Building, Fifth Floor East 370 L’Enfant Promenade, S.W. Washington, DC 20447 General Office Number: (202) 690-6782 Fax: (202) 690-5600 Regional Program Manager Administration of Children & Families 26 Federal Plaza Room 4114 New York, NY 10278 Phone: (202) 205-1582 13 Revised October 2012 7:2 LOCAL - (Territory) Commissioner Department of Human Services #3011 Golden Rock, C'sted St. Croix, U.S.V.I. 00820 St. Croix - phone (340) 773-2323 St. Croix - phone (340) 718-2980 St. Croix - fax (340) 773-4043 St. Thomas - phone (340) 774-0930 St. Thomas - phone (340) 774-1166 St. Thomas - fax (340) 774-3466 http://www.dhs.gov.vi Assistant Commissioner Department of Human Services 1303 Hospital Ground, STE.1 Knud Hansen Complex, Bldg. A St. Thomas, U.S.V.I. 00802-6722 Phone - (340) 774-0930 Fax - (340) 774-3466 Administrator Department of Human Services 1303 Hospital Ground, STE, 1 Knud Hansen Complex, Bldg. A St. Thomas, U.S.V.I. 00802-6722 Phone - (340) 774-0930 Fax - (340) 774-4673 Program Director Department of Human Services #3011 Golden Rock, C'sted St. Croix, V.I. 00820 Phone - (340) 773-2323 Fax - (340) 718-9763 Child Care Specialist & Processing Coordinator St. Thomas (address, phone and fax - same as above) St. Croix (address, phone and fax - same as above) 14 Revised October 2012 SECTION 8 PROGRAM DEVELOPMENT The revised three year plan was developed based on the Federal Guidelines and narrative format under the Department of Health and Human Services (the Child Care and Development Block Grant Plan and the Federal Register dated August 4, 1992, part II, Department of Health and Human Services Administration for Children and Families 45 C.F.R. Parts 98 & 99 Child Care and Development Block Grants Final Rule. Based on the goals and objectives established for the program year, a calendar of events is prepared, a yearly projection for travel, staff vacations, and training opportunities are also documented. Subsequent year’s application includes a budget based on the assigned level of funding, and a letter of commitment. Accountability for program implementation is maintained through the following methods: 1. Formal and informal weekly meetings with the supervisor of the unit are utilized as a means to keep management abreast of issues related to the program. 2. By the 25th of every month, a monthly report of all activities is submitted to the supervisor. This report is based on the staff monthly report and the program previous months activities, which requires the number of families and children served by category and the total amount of children, providers and dollar amount served by category. 3. Fiscal ledger books are maintained by account code. Each account has the budgeted amount, the expenditure, and the current balance listed by the account assigned to Child Care accounts in the department’s business office. 4. Quarterly financial reports provide a means to monitor the fiscal aspect of the program. Communication is important to the Programs operation. An opportunity for communication is provided to clients on a regular basis when they pickup vouchers, during scheduled recertification or contact with workers via phone, walk-in visits, mail or e-mail. Providers are provided with opportunity for communication on a regular basis when submitting vouchers, picking up checks, or contact with workers via phone, walk-in visits, mail or e-mail. Written communication provided by the program, consists of announcements of training opportunities, program quarterly newsletters, summer program survey, annual program evaluations, handbooks for parents and providers, notification of changes or concerns, and operations manual for each district; which is provided to the public, program clients and providers, as well as staff. 15 Revised October 2012 SECTION 9 PROGRAM MONITORING 1. A current inventory is maintained of available supplies on-hand and equipment purchased within a specific period of time. 2. Staff meetings are held bi-weekly on each district to discuss accomplishments and/or issues and update staff of future goals. 3. Four unit staff meetings are held annually to discuss achievements, issues and current and future goals for the unit. 4. Program evaluations are solicited from parents and providers such as market rates in the form of a written or verbal questioner or survey. 5. Region II provides oversight of the program by approving plans, reviewing reports, and evaluating compliances, by phone, e-mail or written correspondence. 6. Verification is conducted during initial eligibility determination based on information obtained from applicants or clients; however, periodic reviews are conducted, and any discrepancies identified are referred to the program’s supervisor for further evaluation and/or investigation. 7. The fiscal ledgers are completed and justified quarterly, and two-yearly evaluations of records are conducted. - 8. The staff monthly reports are reviewed and coordinated monthly with the program goals and objectives. 9. Federal report such as the 800 report is accumulated and compiled by fiscal year, from information entered into the Child Care System, to be reported at the end of the calendar year. 16 Revised October 2012 SECTION 10 PERSONNEL ADMINISTRATION Each staff receives a job description, a copy of the personnel policies, and a copy of their job expectations at their initial employment with the program and when changes are made accordingly. Initially, staff is oriented to the program and given a copy of the plan and Federal Guidelines. The new staff persons is placed on a six month probationary status and evaluated at three month intervals until the completion of their probations. During this time, staff completes their own self-evaluation, training needs are identified, and as training opportunities become available, staff is requested to participate. Two record reviews, containing individual functional, operational and behavioral performances are completed annually along with a formal yearly performance evaluation. Coordination with all staff persons is essential for smooth operation. Each staff is to attend bi-weekly staff meetings and report on their accomplishments, goals, and issues related to the program. Minutes are maintained of all meetings. At the end of each month, staff completes a monthly report indicating their month’s activities. Finally, any training staff attends is summarized and shared with all staff. 17 Revised October 2012 SECTION 11 PROGRAM DIRECTOR The Program Director is responsible for overseeing the day to day operation of the Subsidy, Resource & Referral program. The Program Director reports directly to the Administrator. 11:1 RESPONSIBILITIES 1. Develop policies and procedures for implementing the program. 2. Monitor the compliance with federal and local regulations. 3. Monitor the financial expenditures against the budget. 4. Prepare the CCDF State Plan including a narrative and budget. 5. Submit an itemized list of expenditures for the program, to the Administrator. 6. Supervise four staff persons for two districts. 7. Determine supplies needed and maintain an inventory of supplies and equipment. 11:2 STAFF Each district is assigned two staff. The positions include, but are not limited to: 1. Child Care Specialist – Responsibility is determining and recertifying the eligibility status of the applicants and clients, as well as maintaining waiting list (See: Section 12) 2. Processing Coordinator – Responsibility is initiating, coordinating and documenting provider’s information, as well as preparing, issuing and processing of vouchers. (See: Section 14). 18 Revised October 2012 SECTION 12 CHILD CARE SPECIALIST The Child Care Specialist is responsible for maintaining an accurate and current individual case file for each family determined eligible. The case file is the permanent record that contains the application and materials supporting the application, the eligibility decision, and all documentation and verification supporting eligibility factors. 12:1 AVAILABLE SLOT A specific number of available slots are determined by the Program Director to be filled according to the availability of funds when slots become available due to the number of children no longer in need of child care assistance. The Child Care Specialist decides whether the available funds are sufficient to fill the priority needs of an infant, preschool, afterschool, special needs or summer camp child(ren). When funds become available the Child Care Specialist verifies the applicant information on file and sends an appointment letter to the applicant, by certified mail. 12:2 ELIGIBILITY DETERMINATIONS Applicants or clients are determined eligible by family size, gross income, and the amount received from child support, if applicable using the income eligibility guidelines established by the Department. An applicant or client can also be attending school, completing training, and/or volunteering for 30 hours per week. 12:3 DOCUMENT REQUIREMENTS All applicants or client needing child care assistance are required to provide documents to process and complete an application. 12:3-A INCOME All employed applicants or clients are given an income verification form, requiring that their employer complete and sign the form. Documentation of income can be established by use of income verification, and two consecutive weekly, bi-weekly or monthly recent pay stubs. Other acceptable sources of income verification that can be used, but not limited to:  Job Letter  Business Record 19 Revised October 2012  W-2 current tax year  Other current and reliable documentations However, if applicant or client is being paid in cash, an original notarized job letter is required from the employer. Income Sources – Included, but not limited to:  Wages (gross)  Child support  Military income  Self-employment (tax documents)  Social Security benefits (household)  Spouse income (if living in household or married)  Stipends  TANF allotment  Unemployment benefits Income Sources – Excluded, but not limited to:  Any member residing in the household under 18 years  Food Stamps  Foster Care allotment  Grant or loans  Housing assistance  MAP allotment  Savings  Tax refunds  Teen summer employment (counted if applicant or client)  WIC allotment 12:3-B SCHOOL, TRAINING/VOLUNTEER Applicants or clients attending school or training programs are required to provide an original letter signed and dated by the administrator or registrar, documenting the days the student attends, the hours the student attends and expected graduation date. A copy of their class scheduled is also acceptable. The program does not accept on-line or correspondence course as an eligibility factor. Applicants or clients, who are working under 30 hours per week or attending school part- time, which does not provide sufficient hours to qualify for the program may volunteer their services by selecting a reputable tax-paying establishment to make up the qualifying hours with one of the following, but not limited to: 20 Revised October 2012  Agency (governmental or private)  Hospital  School Applicants or clients, who are not working or attending school full time, can combine activities interchangeably, such as:  School and training/volunteer  Work and school  Work and training/volunteer  Work (2 part-time jobs) 12:3-C VITAL DOCUMENTS A birth certificate or passport is required for each adult whose income will be used to determine eligibility and for each child in the home under the age of 18; however, if a birth certificate or passport is not available, the following documents are acceptable:  Baptismal Certificate  Marriage Certificate  Court documents  Immigration documents Social security cards for each adult and child(ren) in the household can be accepted, copied are maintain in the file if provided; however child care services cannot be denied if social security cards are not provided or refuse. Immunization record or exemption letter is required for each child in need of child care assistance. Photo identification is required to validate the applicant identity, and the following documents are acceptable:  Passport  School picture I.D.  Valid driver license  Voter registration card  Military documents  Employee I.D. card 12:3-D SPECIAL NEEDS Applicant or clients with special needs children between the ages of birth to 19 years are required to provide documentation by a physician or a health care professional, such as 21 Revised October 2012 physician’s assistance, documenting the child special need, whether physically or mentally incapacitated. 12:3-E FOSTER, PROTECTIVE & INTAKE SERVICES Foster parents require a referral documenting the need for child care services. Foster parents are not required to provide proof of employment as; their income is not a factor in determining the child eligibility. Protective services parents require a referral from the CYF or OIES division or a court order documenting that the child is under protective order and that it is necessary for the child to be placed in a child care facility. Protective services parents’ income, employment or educational program must be recorded. If unavailable, document that attempts were made to obtain information. Each case will be reviewed to determine eligibility and co-payment. Adoption of child(ren) by a foster parent without subsidy, are subjected to the same income and support requirement as a regular client; however, if the adopted parent is receiving a subsidy, they are not required to provide income or child support. Children under protective services must reside with a parent of loco parentis and not in a congregate setting. In addition, a child age can be exempt only by a court order within the V.I. code. 12:3-F CHILD SUPPORT Child support income is required for SR&R eligible children and is calculated for determining income. The following factors are used as support by supporting parents:  Paternity and Child Support documents  Purchased items are valued in dollar amount, a notarized letter is required  Social Security benefits  Voluntary support, a notarized letter is required Additionally, proof is required for the non-supporting parent, including, but not limited to:  Death certificate  Disability letter  Incarceration document  Military letter  School/training letter  Court orders 22 Revised October 2012 12:4 APPLICATION PROCESS 1. The applicant or client eligibility is determined, by the income, child support, family size, and age of the child. 2. The applicant or client selects the provider of their choice, if one has not been selected. If the applicant or client request provider assistance, a list of providers is provided, and the applicant may choose a licensed facility, or an informal provider, who is a relative or non-relative. 3. The applicant or client is provided with information on the program, informed of their responsibility to the agency and their child care provider. 4. In order to proceed, necessary information is entered into the Child Care System, which compiles the information, calculates the co-payment (if any), and provide a computer-generated case number. 5. The system generated application is then printed and reviewed by the applicant or client. The application, Parent - Agency agreement, and Consent forms are signed and copied. The originals are kept on file and the client receives a copy. 6. The file is then given to the Processing Coordinator for voucher(s) to be printed. 12:5 CHANGING PROVIDER  The client is required to notify the current provider and Child Care representative that the child will no longer be attending, prior to the change.  The client is given a Change of Provider form to be completed by both the parent and the current provider; however, if any discrepancies, such as outstanding payments are identified, voucher for the new provider may be delayed, until the outstanding balance is paid in full.  Once the change is submitted, verified and approved, the change is recorded in the case file and the Child Care System and the Processing Coordinator is notified. 12:6 DETERMINING SUBSIDY AMOUNT The criteria for determining the amount of the child care subsidy are based on the following, but not limited to:  The child age  The co-payment amount  The provider fee  The total countable income  The hours of care 23 Revised October 2012 12:7 INELIGIBILITY  All applicants who are found to be ineligible receive a written notification, either in person or by mail.  Any client who have received child care services, that is found ineligible due to false information, is require to repay the Department according to the terms and agreement provided by the Department. 12:8 RECERTIFICATION Recertification is conducted every six months, within the same month the child care services ends. A new application, Parent-agency agreement, and updated documents are required and must be verified. If a client fails to keep the schedule appointment a new appointment is provided. Recertification must be completed prior to the client receiving the child care assistance for the next six months (or less). Additionally, a client must be notified of their continue eligibility or ineligibility in writing, by hand or by mail. 12:9 REPORTS Monthly reports are submitted to the Program Director by the 25th day and consist of the following:  Total number of closed families and children  Total number of families and children enrolled in the program  Total number of new families and children enrolled Periodically, the Program Director will request reports pertaining, but not limited to:  Children turning 5 or aging out of the program  Information for federal reports  Total children on the program  Waiting list totals  Statistical or historical information 24 Revised October 2012 SECTION 13 CASE FILE MANAGEMENT 13:1 GENERAL CASE FILE INFORMATION The Child Care Specialist is responsible for maintaining an accurate and current individual automated and paper case file for each family determined eligible. The case file is the permanent record and contains the application and materials supporting the application, the eligibility decision, and all documentation and verification supporting eligibility factors. The case file includes notes and changes in case status as in the Child Care System and each file information is verified and updated every six months. Items entered into the case file must be clear and complete enough so that any person who views the file will be able to easily reconstruct what action occurred, why it occurred, who took the action and when it occurred. The individual family case record shall be initiated after the content verification and shall be completed once eligibility is determined. If the case is determined ineligible or if the application is withdrawn; the forms completed to that point in the application process will be stapled together and placed in a file for ineligible/withdrawn applications that is separate and apart from the case files for eligible or closed cases. All client’s case file must be labeled with the name and the case number assigned by the Child Care System. 13:2 CASE FILE ACCESS The client, upon written request may have access to records and files regarding his or her participant. The record will be made available for inspection during normal working hours, and the Child Care Specialist or Child Care staff is required to be present during the inspection. Documents contained in the client file may not be removed by the parent/custodian; however, a requested document will be copied and provided to the parent/custodian. An unauthorized representative may not have access to the files without a notarized statement signed by the parent/custodian. Information concerning pending investigations or criminal prosecutions will be withheld. The Child Care Specialist will withhold confidential information such as names of individuals who have disclosed information pertaining to the household without the client knowledge. 25 Revised October 2012 13:3 CASE FILE CONTENTS A client file consist of all of the following pertinent information includes, but not limited to:  Application – signed  Child support documents  Consent for the Release of Information – signed  Copies of birth certificates and social security cards for all children to include client on the program (if provided)  Correspondences  Eligibility Determination  Immunization card or Exemption letter  Income Verification and check stubs  Narrative - documenting all contact  Parent/Agency agreement -signed  Picture Identification  Proxy Form 13:4 CASE FILE EXCHANGE The process required for exchanging a client file in the event the client wishes to relocate to attend school, perform military duties, or handle medical emergencies, while the child continues to receive child care services are as follows: A Case Exchange form must be completed within the eligibility period and the authorized person’s information will be used to determine eligibility. The authorized person is required to submit the following to process the case file exchange:  A power of attorney or legal court document  Birth certificate  Income verification and two last check stubs  Photo I.D.  School letter from education/training program (if applicable)  Social security card (if provided) A new file will be created in the authorized person’s name. If the authorized person in not in a activity or meets the established requirements, the child care services will be provided for the grace period, then the case will be closed. 13:5 CASE FILE ORDER All documentation, are to be filed in a 6-part case file folder and labeled in the following order: 26 Revised October 2012 13:5-A Left Side of Section 1 1. Eligibility Determination 2. Narrative 13:5-B Right Side of Section 1 1. Application (computer generated) 2. Parent/Agency Agreement for Receipt of Child Care Subsidy 3. Income Verification 4. Education/Training Verification 5. 2 Last Check Stubs 6. Referral (color coded based on nature of service) 13:5-C Left Side of Section 2 1. Copies of Birth Certificates for the Household 2. Copy of Picture ID 3. Copy of Immunization Record 4. Copy of Social Security Cards for the Household (if provided) 5. Proof of Application from the Social Security Administration (if provided) 13:5-D Right side of Section 2 1. Child Support Information 2. Notarized Letter of Support 3. Social Security Benefit Documents 4. All Absentee Client Documents (decease, incarcerated, military, school, etc.) 13:5-E Left Side of Section 3 1. Consent for the Release of Information 2. Proxy Form 13:5-F Right Side of Section 3 1. Miscellaneous Correspondence 2. Inactive Documents 3. Check List Exception: Jobs and Summer Only cases are filed in a regular case file. 27 Revised October 2012 13:6 CASE FILE RETENTION All closed cases over 24 months old should be placed in storage, with the exception of fraud referrals, cases with administration hearings, and families with active overpayment recoveries, should be maintained on-site for the duration of the recovery period. Closed cases over 10 years old must be destroyed, except for cases with improper payments that have not been repaid and cases under investigation. 13:7 CASE FILE TRANSFERS The process required for a client relocating to another island and is in need of continued child care services: 1. The client is required to notify the Child Care Specialist in their district, by completing a transfer form; 2. The client is required to notify the current child care provider in her/his district of the last day the child will receiving the subsidized care; 3. The Child Care Specialist is required to enter a notation in the narrative, place the transfer form in the case file, transfer the entire case file to the island of choice, and note the transfer on the monthly report; 4. The client will continue to receive subsidy for two months, until new eligibility information is received by the Child Care Specialist in the island of choice; 5. For fiscal year report, the district providing services for the greater amount of months will count the client, (client cannot be counted twice territorially). 13:8 CASE FILE TRANSITION A Jobs client can continue to receive child care assistance, providing their assignment with the Jobs program is completed and they become gainfully employed or attend a school or training program. The client is required to provide all documentation requested to continue receiving assistance. Once eligibility is met the client will continue to receive child care assistance without interruption based on their current activity. 28 Revised October 2012 SECTION 14 WAITING LIST 14:1 GENERAL WAITING LIST INFORMATION Each Child Care office will establish and maintain a Waiting List to plan for possible shortfalls in funding for subsidized child care and to help ensure that child care is provided to families with priority needs as identified in the state plan. The Waiting List shall prioritize families interested in receiving subsidized Child Care who meet preliminary eligibility requirements. The Waiting List is organized by head of household with a separate entry for each child for whom child care is being requested. An active waiting list is maintained and any person(s) who contact the SR&R program after the waiting list is established will be recorded in chronological order, according to the program’s established priority needs. Upon the availability of funds, the prioritized waiting list is activated, and applicants are contacted via certified mail. 14:2 CREATION OF WAITING LIST A waiting list is created when families request subsidized child care assistance and funds are unavailable. The Child Care Specialist collects the basic information regarding their income and service need on the Subsidy, Resource & Referral - Preliminary Application. Based on the information provided, a preliminary determination is made regarding their eligibility. An eligibility determination would not be possible to establish for someone completing a preliminary application that is seeking employment, is not attending school, or have not given birth. However, a pre-application will be accepted after their situation changes. It is important to note that each child care request must be entered individually. There must be a separate entry for each child for who care is being requested even though they are all members of the same household. Each child in a household may have a different service need which has to be considered in establishing their individual service priority. For example, not all children in a household may be in need of child care for protective service reasons; only the child in a protective service situation will have top priority. Another reason each child must be entered individually rather than as part of a household unit is that activation from the Waiting List is based on the service needs of an individual child in relation to the type of child care available. An after school child care slot may be 29 Revised October 2012 suited for one child in the household but not for another child who is younger and needs full-time care. Each child would have to be activated individually as a suitable slot becomes available. 14:3 PRELIMINARY ELIGIBILITY Families interested in receiving subsidized Child Care must meet preliminary eligibility requirements relative to income and service need, in order to be placed on the Waiting List. The eligibility is considered to be preliminary as it reflects the families’ circumstances at the time of the request and must be reevaluated at the time a child care slot, suitable for the child becomes available. A family is determined preliminarily eligible, if their annual gross income (earnings and child support) is below the maximum annual income for their particular family size per the following eligibility table: Eligibility Table (Effective October 2011) Family Size Maximum Annual Inc. – 85% Maximum Monthly Inc. – 85% 2 $30,354.35 $2,529.52 3 $33,023.35 $2,751.94 4 $35,692.35 $2,974.36 5 $38,361.35 $3,196.77 6 $41,030.35 $3,419.19 7 $43,699.35 $3,641.61 8 $46,368.35 $3,864.02 9 $49,037.35 $4,086.44 A potential applicant can contact the office to determine if they are eligible to receive services based on income; but they must complete a pre-application form prior to receiving child care services unless the case is referred as a priority case from an interagency division. The basis of need for the child care services must be considered by the Child Care Specialist as following:  Intake (protective services) Intervention – (foster care)  TANF/JOBS  Special Needs  Teen  Very Low Income  Students  Head Start  Regular  Summer 30 Revised October 2012 If the applicant’s basis of need is any of the above and their annual gross income is below the maximum limit for the particular family size, the family meets the preliminary eligibility requirements and they can be placed on the waiting list. The specific position on the Waiting List is dependent, on the service need. 14:4 PRIORITIZATION OF SERVICE NEED As part of its planning process, the Subsidy, Resource & Referral program establishes a set of service priorities based on the client circumstances. The basis of need service priorities as incorporated into the Child Care System are as follows: 1. Protective Services 2. Teen Parent 3. TANF/JOBS 4. Special Needs 5. Very Low Income 6. Intake/Intervention 7. Other  Foster Care  Regular  Head Start  Summer  Student The highest service need is Protective Services and any child whose request for care is based on this need is not only automatically eligible, (once funds are available) they have the highest priority of any case. They are placed first on the Waiting list above any other case except for another protective situation that may be awaiting a child care slot. Basis of service needs 2 through 6 have their own priority but these priorities are not absolute; the priority assigned to these cases means that they have a higher priority than those below them and consequently get placed higher on the waiting list. A priority 7 case still qualifies the family for child care but there need is superseded by all but other 7’s. 14:5 WAITING LIST MAINTENANCE To ensure that the Waiting List is accurate the Child Care Specialist must contact by phone any applicant who has been on the Waiting List for more than 90 days to inquire if the individual still has a service need and if their income continues to be below the maximum income level for the particular household size. The Child Care Specialist shall record the date of contact and note the continuing financial eligibility and service need. Applicants who fail to respond to this inquiry 31 Revised October 2012 regarding their need for assistance or whose income and child support would appear to make them ineligible, must be purged from the Waiting List. Eligibility will be determined based on the current applicant’s circumstances, in the event the priority needs of the applicant changes. 14:6 WAITING LIST PROCESS All families requesting subsidized child care must be entered on the Waiting List as a child is selected for an available child care slot based on their priority need. All child case is “activated” from the Waiting List through the Child Care System, and a family cannot become an active child care case without first going on the Waiting List. Once a pre-applicant is on the Waiting List, it can be made an active child care case through the activation process in the Child Care System. 32 Revised October 2012 SECTION 15 PROCESSING COORDINATOR The Processing Coordinator initiates, coordinates and compiles provider’s documents, as well as prints and distributes vouchers to families determined eligible by the Child Care Specialist and process vouchers for monthly payments to child care providers. 15:1 LICENSE PROVIDER A license provider, who expresses their interest in participating in the Subsidy, Resource & Referral program, will be provided with information about the program and provided with a letter listing the required documents. Document requirements are as follows:  Provider Agreement – Authorization for Payment (3 original copies) One copy will be provided to Provider, Subsidy & Property & Procurement  Current license  Fee Schedule  Operational Schedule or School Calendar  Resolution (include board members, if necessary)  W-9  ACH/Electronic Payment Vendor Request Form (Direct Deposit)  Any other requested documents. When the documents are returned, the documents are evaluated, and submitted for approvals. Upon final approval or denial, a letter will be sent to the provider indicating their participation status. If the provider is pending documents or if documents are incomplete, the provider will be notified by mail or in hand. In the event the provider fails to provide the requested documents after 30 days, the following course of action will occur:  Send a certified letter requesting the pending document. Failure to provide the requested document,  Another certified letter will be sent regarding the participation status. 15:2 INFORMAL PROVIDER An informal provider, who expresses an interested in the program, must complete a home inspection. The following criteria are necessary prior to receiving services: 33 Revised October 2012  Must not be residing in the same household of the client or child;  Must be 18 or older;  Must complete a home inspection;  Must be approved, prior to approval of payment for providing child care services. In addition, the following steps are required for inspection:  Complete an Informal Provider - Request for Inspection form.  Pass a health & safety inspection, which is conducted by licensing unit. If there are any concerns, technical assistance will be provided.  Complete a NCIC, and any other necessary requirements, once inspection is approved.  Upon home approval, the informal provider will complete the following: o Provider Agreement - Authorization for Payment form – 3 original copies o Fee Schedule o Operational Schedule o Affidavit o W-9 o ACH/Electronic Payment Vendor Request Form (Direct Deposit) o Any other requested documents.  Provider Agreement – Authorization for Payment forms and requires documents are submitted for approval and signature.  Payment becomes effective upon document approval and signature, and no back payment will be provided prior to final approvals.  The process could be completed with 6 weeks: 2 weeks for inspection, 2 weeks for provider to comply with submitting requirements and 2 weeks for final approvals, providing there are no unforeseen issues. 15:3 PROVIDER DOCUMENTS Upon approval of provider’s documents, the specific document will be submitted to the designated person:  Provider Agreement form is submitted to licensing unit to enter or update information in the Child Care Database System.  Direct Deposit form and a copy of a blank check or a bank statement are submitted to business office.  W-9 submitted to Property & Procurement for a vendor number with a justification letter and a copy of the license.  Originals and copies of documents are filed in individual provider file. 34 Revised October 2012 15:4 VOUCHER PREPARATION Once the client and provider information is entered into the Child Care Database System, the voucher can be printed. Preparation of voucher begins with the computer generated information requested on the voucher:  Head of Household registration number (the client case no.)  Provider name  Date of Issuance  Computer generated voucher number  Child name  Child social security number  Voucher valued amount  Date of service to be provided  Provider Signature Line  Provider Mailing Address  Provider Social Security number or EIN number  Head of Household signature The child age determines the amount paid to the provider, thus it is important for the Processing Coordinator to be aware of the children in the program, particularly when the child ages from an infant to preschool, and from a preschool to afterschool and when the child make his/her 13th birthday. After the voucher is prepared, it is logged in the voucher log, under the following heading:  Date of issuance  Child name  Voucher number(s)  Voucher valued amount  Client Signature 15:5 VOUCHER DISTRIBUTION Voucher distribution is provided within a two-week period in the month. Each client is given an appointment date during the distribution period. All clients or their proxy are required to sign the voucher log indicating receipt of the voucher. An attendance certificate is also provided to the clients or providers, which indicates the enrolled child attendance for the month. The attendance certificate is required to provide the following: 35 Revised October 2012  Child’s birth date  Child’s name  Provider’s name  Provider’s signature  Provider’s social security number or EIN number The provider signature on the attendance certificate indicates that the child (ren) listed did in fact receive services. 15:6 VOUCHER BASED ON ATTENDANCE Vouchers are created and paid for a child in accordance to blocked hours based on attendance as follows: Infant & Preschool  1 week (40 hrs.)  2 weeks (80 hrs.)  3 weeks (120 hrs.) or  4weeks (160 hrs.) Afterschool  1 week (20 hrs.)  2 weeks (40 hrs.)  3 weeks (60 hrs.) or  4 weeks (80 hrs.) 15:7 VOUCHER ADJUSTMENTS The following circumstances may cause a voucher to be adjusted or prorated:  Child did not attend for more than one consecutive week. (Exempt if the child is sick, have a medical or family emergency).  Child started attending the facility for a specific period of time. (Ex: one week in the month).  Closure of facility in excess of 3 consecutive days, excluding major federal holidays such as: Easter, Carnival, Christmas, and any other instances exceeding 3 consecutive days in a given week. 15:8 VOUCHER VOIDING Voucher are voided by the Program Director or designee and recreated by the Processing Coordinator for the following reasons: 36 Revised October 2012  Case close  Change of provider  Child did not attend  Child relocated  Facility close  Incorrect amount  No longer in need of assistance  Parent already paid out-of-pocket  Over Payment  Under payment 15:9 VOUCHER REPLACEMENT A client or provider can request an Affidavit of Lost Voucher form to replace a lost or misplaced voucher, in the event a voucher is lost, stolen or destroyed. Once the form is completed, the Processing Coordinator verifies if the voucher was return for processing or was paid. If the voucher was not returned, the voucher would be reprinted and marked “REPRINT” and reissued to the client, providing the voucher has not been auto voided or the period of service has not passed 90 days. 15:10 VOUCHER APPOINTMENT CARD REPLACEMENT A client can request a Voucher Appointment Card Replacement form, in the event a client loses his/her appointment card. If a client does not bring the appointment card for pickup, a replacement card will be provided, or a business card (if applicable) may be used as an option to record the next appointment date, however, if the appointment card is full, a new card will be issued. 15:11 VOUCHER PROCESSING The voucher, which contains five carbonless copies, is signed by the parent and the provider.  The white copy is given to the parent, by the provider;  The green is kept by the provider; The provider then returns the remaining copies for payment with a copy of the attendance certificate and invoice.  The yellow copy is submitted to the St. Thomas fiscal office (Business office) for payment; 37 Revised October 2012  The pink and goldenrod copies are held in a provider file, maintained by the Processing Coordinator. Voucher processing is conducted between the last days of the month until the 5th day of the following month. In order to ensure prompt payment, providers are instructed to return all vouchers, attendance certificates and invoices, no later than the 5th day of the month following the month of service. Any voucher received after the 5th day will result in a delayed payment and will be processed the following month. 15:12 PROCESSING REQUIREMENTS The following documents are required for processing voucher for payment: 15:12-A ATTENDANCE CERTIFICATE(S): The attendance certificate must list the provider, the period of services, the name of the children, the child (ren) date of birth, provider signature and tax identification number or social security number. 15:12-B INVOICE(S): The invoice must include name of the provider, mailing address, phone number, an unduplicated invoice number, and the name of the child (ren) services were provided for during the month(s), the total amount of children, total dollar amount, and provider signature. If more than one month of vouchers is listed, the child(ren) must be identified by name, month and amount. 15:12-C VOUCHER(S): The vouchers must be signed and dated by both client and provider, and must not exceed the 90 days of the valued period. Processing vouchers for payments is conducted by the Processing Coordinator by means of the Government ERP system. The ERP system files are generated to a purchase order, and the following steps are conducted:  Enter a requisition from invoices into ERP system  Await approvals, prior to receiving a purchase order,  Conversion is done by ERP system to generate a purchase order,  Receive report,  Submit hard copies – invoice, yellow copy of voucher and purchase order, to fiscal office for payment,  Print checks, done by the Department of Finance.  Distribute check to provider by mail, in person, by authorized representative, or by direct deposit. 38 Revised October 2012 The Processing Coordinator enters information in the Child Care System, indicating when and if the voucher was received. The information is generated for monthly reporting purposes. 15:13 PROVIDER FILES Files are maintained on all providers and all pertinent information and require documents are contained in the file as following:  Attendance Certificate (original)  Completed inspection and police report (informal provider)  Correspondences  Direct Deposit Form (copy)  Fee Schedules  Fingerprint (informal provider)  Invoice  License (current)  Narrative  Provider Agreement - Authorization of Payment  Resolution  Vouchers - (pink & goldenrod copies)  W-9  All documents relative to the provider 15:14 RECONCILIATION At the end of each month, the Processing Coordinator generates a list of child care providers paid for the month from ERP system. Reconciliation is conducted to ensure that providers have been paid. 15:15 REPORTS A monthly report is prepared by the Processing Coordinator indicating the following:  The total number of vouchers paid  The total value (amount of) vouchers paid  List of providers paid Occasionally, the Program Director will request information pertaining to:  Children  Payments  Providers  Any other related reports 39 Revised October 2012 SECTION 16 GENERAL INFORMATION 16:1 AGE DISALLOWANCE/DISCOUNTINUANCE  After a child turns 5 years, between September 1 - December 31, his/her preschool fees will be discontinued effective Jan 1, of the following year however if after school fees are needed it will be provided.  After a child turns 5 years, between January 1, to June 30, his/her preschool fees will be discontinued effective July 1, of the same year however, if afterschool fees are needed it will be provided.  After a child turns 13 years, the child will no longer receive afterschool assistance, (except special needs or court order).  After a child turns 19 years (special needs or court ordered) he/ she will no longer receive child care assistance. Children that make their 13th or 19th birthday will be allowed to receive voucher for the month; however, beginning the following month after their birthday the voucher will be discontinued. 16:2 APPEAL When an adverse action is taken, the client has 10 days from the action to request a written appeal. The client may appeal the following decision:  Family size  Income  Subsidy amount  Termination of child care services A provider or an unauthorized representative may not request an appeal on behalf of the client, and a client may not request an appeal for the following actions:  Action taken as a result of unavailability of funds  Deletion from the waiting list after applicant expresses, they no longer interested or in need of assistance  Placement on waiting list  Position on waiting list The right to appeal may be channeled through the chain of command if client is not satisfied with the decision. 40 Revised October 2012 The chain of command for appealing a case is followed consecutively as followed:  Supervisor  Director  Administrator  Assistant Commissioner  Commissioner 16:3 APPOINTMENTS All applicants and clients requiring assistance are given an initial appointment to either complete a case and/or pickup their vouchers, however when a client fails to keep their appointment, they may contact the office to be rescheduled for a 2nd appointment. If they fail to keep their 2nd appointment the following course of action will occur: Applicant: Applicant(s) will be removed from the waiting list. Client: A certified letter will be sent to the client with a final (3rd) appointment and, if the client does not keep that appointment, no additional vouchers will be provided, and the case will be closed. Vouchers that are not picked up within 90 days will be automatically voided. 16:4 COMBINATIONS OF CARE AND FEES Clients are allowed to combine care providing the combination amount does not exceed the monthly maximum. Preschool and aftercare providing the combined amount does not exceed the maximum of $300 monthly. Preschool and summer providing the combined amount does not exceed the summer maximum of $310 monthly. After school and summer providing the combined amount does not exceed the maximum of $310 monthly. Special needs and aftercare providing the combined amount does not exceed the maximum of $375 monthly. Special needs and summer providing the combined amount does not exceed the maximum of $375 monthly. A client is not allowed to receive summer camp rates for preschool or afterschool child(ren) in the care of an informal provider. A client will not be reimbursed for paying their child care services out-of-pocket, nor is allowed to receive child care services within the same month the payment was made; unless the entire balance for the month was not paid. Child care assistance is not allowed or will not be provided for a child, while the child is being assisted by another entity such as, but not limited to: 41 Revised October 2012  AmeriCorps  Early Head Start  Head Start  Labor  Any other organization or establishment that provides grants or child care assistance. 16:5 COMPLAINT PROCEDURES A client may make a written complaint by completing a Complaint Form when a situation in the facility warrants an investigation to include, but not limited to:  A provider is not meeting licensing regulation  Suspicion of abuse and neglect  Program violation A provider may make a written complaint by completing a Complaint Form when a situation may warrant an investigation of, but not limited to:  A client is not meeting her/his child care requirements  Abuse and neglect  Program violation 1. Complaints must be logged in numerical sequence. The information relative to date, nature of complaint and source (if disclosed or anonymous) is to be recorded by the individual taking the complaint. 2. Supervisors will be responsible for assigning investigations. 3. Child Care Complaint Report form must be fully completed.  One copy will be placed in the appropriate provider record  One copy will be place in the Complaint File, a separate record of completed reports 4. Findings and recommendations are transmitted to the Supervisor for disposition. 16:6 COMPLEXITIES Temporary delays occur due to various reasons, examples follows:  Age and capacity requirements  Case not registered in database  Database inoperable (system malfunction) 42 Revised October 2012  Expired provider agreement  Facility is temporarily or permanently closed (client may choose another provider)  Failure to keep appointments (new appointment provided)  Failure to report changes  Incomplete case files (pending documents or signature)  Informal provider has not completed inspection  Not a proxy (completed proxy form must be in case file) or co-applicant  Pending documents  Program violations  Provider is unlicensed or the license has expired  Provider has not been selected  Provider is not listed on licensing listing (regular or summer)  Provider is not registered with the program  Proxy did not provide a valid I.D.  Unavailability of funds 16:7 CONSUMER EDUCATION & INFORMATION Consumer education and information is provided to clients, providers and the general public by the following mediums:  Advertisements  Client handbooks  Conferences  Newsletters  Program brochures  Provider handbooks  PSA  Technical assistance  Training workshops 16:8 CONFLICTS OF INTEREST Any internal or external conflicting or unethical behavior, practices or influences that will compromise and become detrimental to the integrity of the program will not be permitted, such as, but not limited to: Exhibiting preferential treatment Exhibiting favoritism Expediting or circumventing the normal business practice to family, friend or co-workers when seeking or receiving child care services, and any other compromising integrity characteristics, actions or activity that would appear 43 Revised October 2012 compromising in nature and be demonstrated as unfair and unethical business practices on behalf of the program. Child Care Specialist may not determine eligibility or recertify cases for family members (parents, children or other immediate relative) needing child care services. Those cases will be referred to and determined by either the Child Care Specialist located on the opposite island or be completed by the supervisor. If either person is unavailable the case will be completed and submitted to the supervisor for evaluation, review and signature. 16:9 CO-PAYMENTS & OUTSTANDING BALANCES Clients are responsible for paying their co-payments and tuition balances (if applicable) to the provider. If a client fails to pay their co-payment or outstanding tuition balances after 60 days, from a previous or current provider, no future voucher will be issued until the outstanding balances are paid in full. A receipt or written document from the previous or current provider will be accepted as proof that the outstanding balance has been paid in full. 16:10 DISCOUNTS If a provider allows discount fees for multiple child(ren) residing in the same household, the case file and voucher(s) will reflect lower fees for the child or children receiving services. 16:11 FAILURE TO REPORT CHANGES Failure to report changes may result in a program violation which may case:  Case closure  Delay of services  Program violation  Reduction of subsidy amount  Other program violations (see Program Integrity) 16:12 GRACE PERIODS A grace period consists of 2 months of consecutive allowance of continued child care services, due to client temporary disruption or interruption of existing activities to include:  Client completed course study  Displaced worker (company closure)  Economic slowdown or reduction in work hours (under 30 hrs.)  Maternity and Military Leave  School close for summer vacation 44 Revised October 2012  Terminated worker  Seasonal workers The grace period allows for the client to seek another activity within a 2 months period while the child is being cared for. If another activity is not secured within the grace period, the case will be closed. However, if a client voluntarily stops attending school or work, the 2 months grace period will not be granted. 16:13 INACTIVE CASES A case that remains incomplete, pending, and not recertified for more than 60 days consecutively is subject to close. However, if written documentation regarding medical or other emergency is provided, the case will remain open for an additional 30 days, prior to closing. Case that are inactive for the summer months, June, July and August can remain inactive until the beginning of the new school year; however when the school year begins and the case remains inactive for the month, the case will be automatically closed. 16:14 LIST GENERATIONS During the FY, Child Care Specialist must compile and maintain an unduplicated list of participants that receive child care services.  Clients  Children (age category)  Providers  Waiting list 16:15 MAXIMUM ALLOWABLE FEES Fees cannot exceed the maximum allow as established by the Department. The following fees are provided under the established amount based on age: Infants (birth – 2) $300.00 per month Preschool (2-4) $300.00 per month School Age/After school (5-12) $150.00 per month Special Needs (birth – 19) $375.00 per month Summer Camp (3-13) $310.00 per month 16:16 PROVIDER CARE TYPES The following care types are generally used and recognized for ACF’s reporting purposes. 45 Revised October 2012 Child’s Home Care provided by a caregiver in the child’s own home. Family Home Care provided in the family home of the provider (i.e., care provided by an individual by an individual in their own private residence). Generally, family home care is provided only to a limited number of children at any one time. Group Home Care provider in the family home of the provider with the assistance of at least one additional hired staff member. Group homes can provide services to a larger number of children at any one time. Center-Based Care provided in a center-based setting, including programs in school or churches. Relative Care Care provided by a grandparent, great-grandparent, aunt or uncle, or sibling (living outside of the child’s home) of the child by cared for. In addition, for ACF 800 reporting purposes the following are two type of child care setting: Legally operating, unregulated provider is a provider that, if not participating in the Subsidy, Resource & Referral program, would not be subjected to any state or local child care regulations. Licensed or regulated provider are legally regulated or licensed by State designated licensing agent. 16:17 PROVIDER CHOICES Day Care A facility which provides care for 3 or more children that is not related to each other from birth to 14 years of age for any part of a 24-hour day. Preschool A facility which provides care for more than 12 children between the ages of 2 and 14 years of age for less than 24 hours a day, whether under some other descriptive name such as “nursery”, “preschool”, “pre-kindergarten”, “after-school center”, “drop-in center”, or “child development center”, whether or not the facility is operated for profit. Group Home A facility which provides care for 7 to 12 children under 14 years of age for less than 24 hours a day whether or not the facility is operated for profit. 46 Revised October 2012 Family Home A facility which provides care for not less than 3 and no more than 6 children under 14 years of age for less than 24 hours a day whether or not the facility is operated for profit. After School A programs held outside of a regular school day for children ages 5 to 14 years that are developmentally appropriate that include but are not limited to:  Academic enrichment  Personal growth  Cultural activities  Recreational activities  Sports and fitness activities Informal Care A residential structure or the child’s residence where child care services is being provided by a relative or friend for children between birth to 12 years. Summer Camps A license recreational, educational, and cultural program conducted in the summer, for three or less months. 16:18 PROVIDER COMBINATIONS Clients are allowed to receive combined services from multiple providers; as long as the providers has not delivered services within the same period of time and the combined totals do not exceed the monthly maximum.  Center base – center base setting (interchangeably)  Center base – informal setting (interchangeably)  Center base – summer camp (interchangeably)  Informal setting – summer camp (interchangeably) 16:19 PROXY A client or provider must authorize a proxy to receive voucher(s) or check(s), on their behalf by completing a proxy form. A proxy or authorized representative must be 18 years or older and is only authorized to sign for receiving voucher(s) or check(s) with a valid picture identification. A proxy can receive or submit documents and forms on behalf of the client or provider. A maximum of two proxies are allowed for receiving voucher(s) or check(s) on behalf of each client or provider. The initial proxy information will be is keyed into the Child Care System, and the both forms will be placed in individual files. 47 Revised October 2012 If a client change proxy, an adjustment will be made in the Child Care System to reflect the new proxy. A proxy is unauthorized to perform the following:  Complete a case file  Receive vouchers or check(s) on behalf of more than two families or provider(s)  Receive a check (without written authorization)  Request information from case file (without written authorization)  Sign a voucher (without written authorization) 16:20 RE-APPLY An applicant or client may re-apply if:  An applicant or client fails to keep three consecutive appointments.  An applicant or client fails to respond to the certified mailed appoint (expect if someone else signature the certify slip.)  An applicant or client does not 30 hours or are ineligible and their family circumstances change. 16:21 RELEASE OF INFORMATION Releasing information for clients will only be provided to governmental of federal entities with a written authorization or Consent for the Release of Information. General information for providers such as; location, phone number, monthly tuition payment, ages, and any other general published information will be release to the general public. Client information will not be provided over the phone or in person to family, friend or co-workers unless a written request is provided by the client to release the requested information. Exception: Specific information pertaining to the status of a case can be provided to a provider, upon the provider request, such as: If the case is active or inactive If the client is eligible to receive services The client voucher status 48 Revised October 2012 16:22 SECURITY MEASURES In an effort to maintain confidentiality and security, the following precautionary measures are necessary:  Lock all clients and providers case (active, close, pending, incomplete and over qualify).  Provide confidentiality at all times.  Secure clients and providers documents.  Secure individual user name and password.  Secure unattended cases.  Unauthorized access is prohibited to clients or providers files. 16:23 SUMMER ONLY Summer camp assistance is provided to eligible families with child (ren), between the ages of 3 to 12 years who meet the criteria for summer only for a period of 3 months (June-August). After the 3 months summer assistance the client case file will be closed. Clients or applicants can receive summer assistance for:  One additional child for existing clients.  Two children for applicants not on the program. Additionally, summer only applicants receiving summer assistance is exempted from providing child support information. Operators of summer camp are requested to submit a flyer or written correspondence, to the office indicating the following:  Address – mailing & physical  Ages serving  Duration of camp (starting & ending date)  Name of facility  Phone number  Provider Agreement – Authorization for Payment (only for summer camps not on the program year-round)  Summer fee (must indicate whether weekly, bi-weekly monthly, entire summer, etc.)  Any other requested documents A client may choose to send child(ren) to another island within the territory for summer, and a voucher can be printed on the island where the client resides for a provider in another island. 49 Revised October 2012 The Provider Agreement – Authorization for Payment information (if on file) would be sent from the island of choice, to the island where the client reside to be entered in the Child Care System for vouchers to be printed. In the event a parent chooses to use an informal provider for the summer, the informal provider would only receive preschool or afterschool rates. 50 Revised October 2012 SECTION 17 ALTERNATIVE MEASURES In order to maintain clear objectives, direction and minimize service delays, the following alternative measures will be practiced to continue operational flow: 17:1 ALTERNATIVE TO PROCESSING APPLICATION In the event a Child Care Specialist is out of the office for an extended or indefinite period of time, the Child Care Specialist on the other island will complete and recertify cases to avoid lapses in service by:  Accessing the inter-island Child Care System;  Completing the case;  Faxing or e-mailing application to the Processing Coordinator;  Allowing parents to provide pertinent documents and sign the application.  Printing the voucher by the Processing Coordinator. If the Child Care System is unavailable the Child Care Specialist may travel to the opposite island to complete the cases. 17:2 ALTERNATIVES TO PRINTING & PROCESSING VOUCHERS In the event a Processing Coordinator is out of the office for an extended or indefinite period of time, the Processing Coordinator on the other island will print and/or process vouchers to avoid lapses in service by:  Accessing the inter-island Child Care System;  Printing the vouchers/or processing payments. 17:3 ALTERNATIVES TO VOIDING VOUCHERS In the event the Program Director is out of the office for an extended or indefinite period of time, a designed person would be authorized to void vouchers to ensure services are continued without interruption. In the event that either the Child Care Specialist or Processing Coordinator is unavailable for an extended period of time, the Program Director will assist accordingly or designate another staff person. 51 Revised October 2012 17:4 SYSTEM FAILURE OR POWER OUTAGES In the event there is a system failure or power outage, a client providing documents for eligibility determination or recertification or receiving vouchers will be rescheduled. 52 Revised October 2012 SECTION 18 PROGRAM INTEGRITY 18:1 IMPROPER PAYMENTS BACKGROUND In an effort to reduce improper payments and fraud, the Administration has emphasized that efforts must be undertaken with consideration for impacts on eligible families seeking benefits. In November 2009, the President issued Executive Order 13520, which outlines the importance of reducing improper payments in Federal programs while protecting access to programs by their intended beneficiaries. OVERVIEW The Subsidy, Resource & Referral program has the responsibility to meet regulatory requirements to support program integrity and financial accountability to prevent fraud, waste and abuse and correct improper child care payments, establish policies to collect overpayments, and determine case warranting further investigation of possible fraud. The improper payment process encompasses all child care services administered. 18:2 PROGRAM VIOLATIONS amount of subsidy payment to client or provider. Any client or provider suspected of a program violation will be investigated and all steps would be taken to recover any payments or overpayments for which the client or provider was not eligible to receive. 18:3 ERRORS An error consists of any program violations or dishonest use of program funds, even if the violation results in the improper authorization of payment. 18:3-A INADVERTENT ERRORS An overpayment results from a misunderstanding or unintended error on the part of a client or provider. 18:3-B IMPROPER AUTHORIZATION OF PAYMENT An amount authorized for payment during the eligibility or recertification period, which should not have been authorized. 53 Revised October 2012 18:3-C UNDERAUTHORIZATION OF PAYMENT An improper authorization under the amount established or less than the amount that should have been authorized. 18:3-D OVERAUTHORIZATION OF PAYMENT An improper authorization in the excess of the amount established or is authorized to receive. 18:4 RESPONSIBILITIES OF DIVISION STAFF The division staff is responsible to report all incidences of possible or actual program violations or errors by clients or providers in writing or by using the complaint form and submit to their immediate supervisor for further investigation. 18:5 IMPROPER PAYMENT REFERRAL DOCUMENTATION All improper payment will be referred to the immediate supervisor or designee for further investigation. Documentation must be provided in writing and accompanied by all supporting documentation showing that an improper payment occurred. 18:6 IMPROPER PAYMENT REFERRAL PROCESSING All documented improper payment referrals will be investigated by the supervisor or designee. Once the improper payment has been substantiated the supervisor will notify the parties involved that an improper payment occurred and arrange a repayment or recoupment plan; however, if an improper payment has not been substantiated the finding will be documented in the file. 18:7 FRAUD A false representation of a matter of fact, by words, conduct, false or misleading allegations, or by concealment of what should have been disclosed for the purpose of deceiving and intention to deceive the child care program. 18:7-A CLIENT FRAUD  Collusion with the child care provider to receive child care benefits for which the client was not eligible to receive.  Intentionally concealing income used for determining eligibility.  Submitting false and misleading information or documents that, if known may result in the decrease or disqualification of receiving child care benefits. 54 Revised October 2012  Concealing child care needs, based on changes that have affected the client circumstances, that if known would decrease or discontinue child care benefits.  Intentionally withholding or incorrectly reporting household size to receive child care benefits or by adding minor relatives to household size in an effort to become eligible to receive child care benefits.  Intentionally not attending an activity or reporting changes, while continuing to receive benefits after exceeding the allowable grace period, that if known would discontinue or disqualify child care benefits.  Receiving child care benefits for a child who do not reside in the household, temporarily or permanently relocated or is residing with another relative or family member.  Intentionally exchanging a child who is receiving care services for a child who is not receiving child care services, ex: Exchanging a younger child in place of an older sibling who is receiving the maximum child care benefit.  Intentionally concealing child support benefits to become eligible to receive child care benefits, that if reported would decreased child care benefits or overqualified client.  Intentionally leaving a child receiving child care benefits in the care of someone else who is not paid to care for the child.  Intentionally or willfully forging signatures on documents, vouchers and any other correspondences.  Intentionally giving a child to a working relative or other person in an effort to receive child care benefits, while the parent(s) is not working or attending an activity.  Intentionally concealing the child’s parent who resides in the same household of the child and client, who has income, which may decrease or disqualify client from receiving child care services.  Posing as a fictitious parent, claiming fictitious child(ren) or using fictitious document to receive child care benefits.  Intentionally accepting vouchers for decease children. 18:7-B PROVIDER FRAUD  Collusion with client to receive child care benefits for which the client is not attending work, school or other component.  Accepting vouchers for children who are not attending the facility.  Collecting full out-of-pocket payment from client, plus receiving a full or partial amount on vouchers to make up the difference in provider cost for the month.  Submitting false attendance certificate, knowing that a child did not receive services.  Receiving child care payment, while the child is being cared for by another provider, family member or friend.  Accepting child care services for a child from more than one source: ex: AmeriCorps, Labor, military, a grant, directly from the child’s parent or family member, or any other sources. 55 Revised October 2012  Intentionally exchanging child care services for a child who is not receiving child care services, ex: Exchanging the younger child in place of an older sibling that is receiving the maximum child care fee.  Intentionally submitted voucher payments’, knowing the child has aged out of the facility based on the license requirement.  Charging various monthly fees for children in the same age group, who are attending the same hours; except for a special needs child.  Intentionally or willfully forging signatures on documents, vouchers and any other correspondences.  Intentionally submitting vouchers payments for decease children. 18:8 INTERNAL AUDITS Random and planned internal audits will periodically be conducted to ensure appropriate verification, accountability and monitoring to ensure programs integrity. 18:9 REPAYMENT The client or provider will repay all ineligible funds receive from the Subsidy, Resource & Referral program. 18:9-A CLIENTS Clients who have defrauded the child care program will be responsible to repay the program the sum equal to the overpayment.  If the client is an active participant in the program, the next issue voucher will be reduced to reflect the amount overpaid until the overpayment amount is paid in full.  A client will be disallowed to receive vouchers for several months to total the amount overpaid. Ex: If a client is overpaid $900.00 the client will be disallowed to receive child care assistance for 3 consecutive months to exhaust the overpaid amount, if the client is receiving the maximum of $300 monthly.  If the client is no longer receiving child care assistance, the former client will be notified by certified letter of the overpayment and be held responsible to repay the child care program by installments or in full, in the form of a money order, cash or certified check. 18:9-B PROVIDERS Providers who have defrauded the child care program will be responsible to repay the program the sum equal to the overpayment.  If the provider is an active participant of the program, the next check or direct deposit payment will be adjusted to reflect the amount of overpayment, until the 56 Revised October 2012 amount is paid in full. Ex: If a provider has a check for $1,000 and is overpaid $500, the check will be reduced to reflect the $500 overpayment.  The provider may opt to repay by money order, cash or certified check.  If the provider is no longer an active participant in the program, the provider will be notified of the overpayment and be responsible to repay the child care program by installments or in full, in the form of money order, cash or certified check. 18:10 INTENTIONAL PROGRAM VIOLATIONS An intentional act by knowingly and/ or willfully giving false or misleading information, misrepresented, concealed or withheld facts with the intention of receiving child care benefits that should have not been eligible to receive. The following list may contain reciprocated characteristics as mentioned in fraud and that is not all inclusive. 18:10-A CLIENTS  Intentionally receiving child care benefits for a child, whose other biological parent is residing in the same household and is not working or attending any activity.  Intentionally providing false information, to be considered a priority needs in an attempt to receive expedited child care benefits.  Intentionally using vouchers to hold a space for child until the child is ready to attend the facility.  Intentionally refusing to provide requested documents. 18:10-B PROVIDERS  Intentionally accepting children under or over the license requirement.  Intentionally accepting vouchers for a child who is not attending aftercare or afterschool program or intentionally accepting an afterschool or aftercare vouchers to off-set the child’s preschool monthly tuition.  Intentionally receiving vouchers without a valid license.  Intentionally refusing to provide requested documents.  Intentionally accepting a child in an over capacitated facility or at-home setting.  Intentionally verbally expressing or physically exhibiting physical mistreatment or abuse in the presence or close proximity of children in care.  Provider lives in the same household as the child and, or client.  Intentionally endangering the health and safety of a child.  Intentionally caring for more children at-home than is allowed at any given time. 18:11 LEGAL ACTION All legal actions will be referred to the department’s legal counsel for legal advisement and direction, on a case by case basis. 57 Revised October 2012 18:12 COLLECTIONS METHODS The following collection methods will be used to recoup payments owed to the program:  Voluntary payment arrangements  Court ordered repayment  Tax refund interception  Wage garnishment  Referral to a collection agency 18:13 DISQUALIFICATION Inadvertent error will receive a written warning and is responsible to repay any overpayments. Based on the nature and severity of the intentional program violation or fraud, deferment (suspension) from the program will be administered for a specific period of time:  1st offense - 3 months deferment  2nd offense - 6 months deferment  3rd offense - Permanent disqualification 18:13-A DISALLOWANCES A client or provider will be disbarred indefinitely, from receiving child care benefits if they are found guilty of the following:  Conviction of fraud  Found liable civilly liable for fraud  Forgery to receive money under false pretense  Fail to comply with repayment  Illegal business practices 58 Revised October 2012 SECTION 19 DEFINITIONS Adult - A person 18 years of age or older. After school or After care – Providing care before and after regular school hours. Age Category – A category of ages: infant (0-2) preschool (2-4) afterschool (5-12), summer (3-12) special need (0-19) Appeal – A written request seeking a hearing to review an adverse action. Applicant – A person who apply for services on behalf of the child (ren) for which they have physical custody. The applicant must be age 18 or over unless the applicant is married, and emancipated minor, or a minor parent. Appointment Card – A CCDF administered card used for providing schedule appointment for receiving vouchers. Attendance Certificate – A duplicated form listing the attendance of a child (ren) receiving services for a specific period. Authorized Representative – A person authorize to conduct specific business, on behalf of someone else. Auto Void – Automatic voiding of voucher, over 90 days of service by the Child Care System. Blocked hours based on attendance – The hours of care is reflected based on blocked hours associated with the days the child actually received care. Case Number – An individual system generated unique identifying number assigned to a client or provider for receiving services. Categories of Care – Types of child care setting includes: center base, child care home, and in-home care. Change of Provider – A choice of changing one child care provider for another. Child – An individual under eighteen (18) years of age, including children emancipated at fourteen (14) years of age or above. Child Support – Support from absent parent in the form of monetary or value of purchased items. 59 Revised October 2012 Child With Special Needs - A child who has been professional diagnose with a disability. Child Care & Development Fund – A program authorized by Congress through the U.S. Department Block Grant to have one single, integrated child care funding system to assist low-income families through subsidized child care and to increase the availability and quality of child care services. Citizen – A citizen of the United States or a qualified permanent resident. Client – A person in recipient of child care services. Co-Applicant - A person who applies with the client or is counted as a spouse or significant other in the household to determine eligibility. The co-applicant can provide information and recertify the case with the client written consent. Co-Pay – The cost sharing portion paid by client to the provider for child care per child, which is calculated using the child care eligibility determination and sliding fee scale. Custody- Providing care and supervision of a minor through formal agreement, such as: Divorce decree, guardianship, foster placement, or power of attorney. Date of Application – The date the client signs the application. Double Household – The number of adults residing in the household that are legally and financially responsible for the child’s care. Education and Training – A needs category used for determining eligibility to include school, college or a job-training program, full or part-time. Eligible - An individual or family meets the criteria for receiving services. Eligibility Determination – The procedure used to determine client eligibility. The determination is based on the need for service and variables of family size and income. Eligibility Period – The period of time a client is eligible to receive services. Family – A combination of one or more adults and children related by blood or law, or other person standing in loco parentis, residing in the same household. Family Size – A family composition consisting of a parent, and or spouse, and all their dependent children under 18 years of age (related by blood, marriage, adoption, or guardianship) who reside in the same household. Foster Parent – An individual who provides care and supervision as substitute family on a 24 hrs. basis, to a child who is deemed a ward of the DHS. 60 Revised October 2012 Fraud – An act perpetrated by making a false statement and/or withholding information with deceitful intent to obtain or attempts to receive assistance or payment for which he/she is not eligible. Grace Period – An allowance of two consecutive months of continued child care subsidy in the event of an inactivity. Gross Family Income – Total income from all countable sources prior to taxes and deductions. Income Eligible – Applicants who are financially eligible for services based on the current poverty level for a specific family size. Infant – A child between the ages of birth to 24 months. Informal Provider - An individual who is 18 years of ages, who provides child care services in a residential structure, or the child residence, but not residing in the same household of the client and/or child. Invoice – A document listing the itemize names of children for which child care services was rendered for a specific period of time and monthly charge. Intake client – A client referred by the Office of Intake & Emergency Services, who may be at risk of losing their children due to abuse and neglect. JOBS client – A client referred by the JOBS program, who are attending an activity and is in need of child care services. Licensed Provider – A provider with a valid license that meets the legal requirement of the territory (DHS- OCCRS) to provide child care services. Monthly Report – A report consisting of the total child care services provided for the month. Narrative – A document used to record clients contact and other information that is not found elsewhere in the case record. Overpayment – Payments in excess of the allowable amount. Parent – A person related to the eligible child by blood, marriage, or adoption including a legal guardian or other person standing in loco parentis (in the place of a parent). Parental Choice – A federal requirement requiring a client choice of child care arrangement from a variety of licensed or registered providers. 61 Revised October 2012 Preliminary Application – The initial form completed by a prospective applicant to determine eligibility. Provider Agreement – Authorization for Payment – An agreement between the SR&R program and the provider consisting of terms and obligations for receiving payment. Protective Services – Services provided by the agency to protect children from abuse, neglect or exploitation. Proxy – A person authorized to receive vouchers on the behalf of a client. Recertification - The process required for determining whether a client still meets the eligibility for receiving child care services. Recertification Period – A specific period of time required to recertify a case, to determine if eligibility is still met for receiving services. Referral – A written interagency request for child care services. Regular – A term used to distinguish child care applicants or clients based on eligibility factors established by the program. Reschedule – A new appointment date given after the initial scheduled appointment date was missed. Resolution – The act of resolving or determining upon an action, or course of action, method, procedure, etc. (An authorization giving an individual or an organization authority to conduct business in their best interest.) Sanction – A penalty imposed when services is fraudulently obtained. Single Parent – A parent raising a child without any other biological parent or step- parent residing in the home. Sliding Fee Scale – A cost sharing system based on 85% median income and family size. Subsidy Begin Date – The date a client is eligible to begin receiving child care services. The begin date may not be backdated to the previous month; however, it may cover a portion of the cost for the month. Subsidy End Date – The date child care services ends. Summer Camp – A license recreational, educational, and cultural program conducted in the summer, for three or less months. Summer Only – Assistance provided for summer only from June – August. 62 Revised October 2012 Teen (Minor) Parent – A minor who is attending junior or high school, under the age of 19. Verification – The confirmation of facts and information used in determining eligibility, and the amount of the subsidy through the use of written documentation and information obtained from reliable sources, such as: SNAP, their employer, Paternity & Child Support. Very Low Income – An applicant or client whose gross income is below the media poverty level between. Voucher – A monetary substitute used for paying child care services, for a specific child, provider, period and dollar amount. Voided Voucher – The voluntary termination of voucher, no longer valid for services. Volunteer – Services performed willingly without any form of compensation. Voucher End Date – The date no longer valid for provider reimbursement. Update – The process by which a periodic review is conducted on an applicant, client or provider. Waiting List – A list generated from preliminarily application, completed by applicants who meet the financial eligibility and declare a service need, but funding is unavailable. Week – The days between Sunday through Saturday. Working – A person receiving wages or salary for performing services for 30 or more hours. 63 Revised October 2012 SECTION 20 REVISED SLIDING FEE SCALE Government of the Virgin Islands of the United States Subsidy, Resource & Referral Program Revised Sliding Fee Scale Sliding Fee Scale (Revised) - Family Size 4 - Week Co- payment Rate 2 3 4 5 6 7 8 9 10 $- 0 $23,354 $26,373 $29,392 $32,411 $35,430 $38,449 $41,468 $44,487 $47,506 $ 4.00 $23,854 $26,848 $29,842 $32,836 $35,830 $38,824 $41,818 $44,812 $47,806 $ 4.00 $24,354 $27,323 $30,292 $33,261 $36,230 $39,199 $42,168 $45,137 $48,106 $ 5.00 $24,854 $27,798 $30,742 $33,686 $36,630 $39,574 $42,518 $45,462 $48,406 $ 5.00 $25,354 $28,273 $31,192 $34,111 $37,030 $39,949 $42,868 $45,787 $48,706 $ 6.00 $25,854 $28,748 $31,642 $34,536 $37,430 $40,324 $43,218 $46,112 $49,006 $ 6.00 $26,354 $29,223 $32,092 $34,961 $37,830 $40,699 $43,568 $46,437 $49,306 $ 7.00 $26,854 $29,698 $32,542 $35,386 $38,230 $41,074 $43,918 $46,762 $49,606 $ 7.00 $27,354 $30,173 $32,992 $35,811 $38,630 $41,449 $44,268 $47,087 $49,906 $ 8.00 $27,854 $30,648 $33,442 $36,236 $39,030 $41,824 $44,618 $47,412 $50,206 $ 8.00 $28,354 $31,123 $34,892 $36,661 $39,430 $42,199 $44,968 $47,737 $50,506 $ 9.00 $28,854 $31,598 $34,342 $37,086 $39,830 $42,574 $45,318 $48,062 $50,806 $ 9.00 $29,354 $32,073 $34,792 $37,511 $40,230 $42,949 $45,668 $48,387 $51,106 $ 10.00 $29,854 $32,548 $35,242 $37,936 $40,630 $43,324 $46,018 $48,712 $51,406 $ 10.00 $30,354 $33,023 $35,692 $38,361 $41,030 $43,699 $46,368 $49,037 $51,706 Add $3, 140 for each additional family member. 64 Revised October 2012 Agency Payment Rate Infant $300.00 Toddlers $300.00 Preschooler $300.00 Before/After School $150.00 Summer Camps $310.00 Special Needs $375.00 Family Size Annual, Inc. 85% Monthly Inc. 85% 2 $35,711.00 $30,354.35 $2,975.91 $2,529.52 3 $38,851.00 $33,023.35 $3,237.58 $2,751.94 4 $41,991.00 $35,692.35 $3,499.25 $2,974.36 5 $45,131.00 $38,361.35 $3,760.91 $3,196.77 6 $48,271.00 $41,030.35 $4,022.58 $3,419.19 7 $51,411.00 $43,699.35 $4,284.25 $3,641.61 8 $54,551.00 $46,368.35 $4,545.91 $3,864.02 9 $57,691.00 $49,037.35 $4,807.58 $4,086.44 Effective October 2011 - 85% SMI (state median income) (35,711 Annual Income provided by the Bureau of Economic Development 2010) 65 Revised October 2012 SECTION 21 FORMS & LETTERS 21:1 STAFF LETTERS & FORMS Required letters and forms to be used by staff 21:1-A Check List for Child Care Cases 21:1-B Check Pickup Log 21:1-C Eligibility Determination 21:1-D Inter-Office Request 21:1-E Monthly Report (SR&R) 21:1-F Monthly Report Worksheet (SR&R) 21:1-G Narrative Sheet 21:1-H Transmittal 21:1-I Voucher Log 66 Revised October 2012 CHECK LIST FOR SUBSIDY, RESOURCE & REFERRAL CASES ___ Application ___ Birth Certificate(s) – (legal children – birth or court ordered) ___ Change in provider Form (if parent changes provider) ___ Consent for Release of Information ___ Death Certificate ___ Documentation from Justice Department, if a parent is incarcerated ___ Eligibility Determination ___ If self-employed current tax forms ___ Immunization Card(s) or Exemption letter (children on the program) ___ Income Verification and two last check stubs ___ Letter of school enrollment, UVI or training program (if applicable) if working also provide income ___ Letter of guardianship (legal documents, only) ___ Medical Documents (special needs) ___ Narrative Form ___ Parent/Agency Agreement Form Signed ___ Parent who provides voluntary support, (notarized letter stating monthly support) ___ Photo ID ___ Proxy Form (authorizing someone else to pick up vouchers) ___ Referral Forms (Foster Care, Protective Services, JOBS, Intake, or Intervention) ___ Social Security Card(s) (parent, legal children – birth or court ordered) ___ Support Information from Paternity & Child Support 67 Revised October 2012 Department of Human Services Providers Checks for the Month of_____________20____ Center/Provider Name Qty of Checks Available Check Date Pickup Date Print Name Signature 68 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services ELIGIBILITY DETERMINATION SCHEDULE Parent Name: __________________________________________ Family Income: __________________________________________ Child Support: __________________________________________ Add lines 2 & 3 (Total Income) ______________________________ No. of Persons in Family: ________________________________ Co-payment per child _________________ per month. ____________________ _____________ ______________ _________ Child’s Name D.O.B. Provider Monthly Fee ___________________ ______________ ______________ _________ Child’s Name D.O.B. Provider Monthly Fee ___________________ ______________ _______________ _________ Child’s Name D.O.B. Provider Month Fee Eligibility Period: Beginning Date:____________________________Ending Date:______________________ □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 69 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services INTER-OFFICE REQUEST From: Received By: Date: Received Date : To: Assigned To: Assigned Date: Type of Request  Add fees  Close provider(s)  Summer listings  Ages serve  Licensing period (from - to)  Updated listing  Capacity  Licensing status  Other  Change fee(s)  New provider 70 Revised October 2012 OFFICE OF CHILD CARE & REGULATORY SERVICES SUBSIDY, RESOURCE & REFERRAL MONTHLY REPORT NAME: DATE: December 16, 2016 DISTRICT: St. Croix Month: November 2016 PROFILE CHILDREN NEW CLOSE Reg. Jobs Total Reg. Jobs Total Reg. Jobs Total Infants Preschoolers After-schools Special Needs TOTAL CHILDREN Single Mothers Single Fathers Teen Parents Married TOTAL Working Ed. Program Protective Services Foster Care Intake TOTAL FAMILIES 71 Revised October 2012 Monthly Report Worksheet Month:______________________ Year:___________ Status ________ # Client Name Status Infant Preschool Afterschool Special Needs Total 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Families Activity Children SM Edu Inf SF Work Pre Teen PS Aft Mar FP SP Totals 72 Revised October 2012 NARRATIVE SHEET CLIENT NAME: DATE: 73 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services TRANSMITTAL From: Received By: Date: Received Date: To: Assigned To: Transmitted Document(s): Assigned Date:  For approval  For your Information & Files  For distribution  For your request  For your signature  Other Transmitted To: Business Office _____________________________________________ Commissioner Office _____________________________________________ Property & Procurement _____________________________________________ OCCRS _____________________________________________ Other _____________________________________________ □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 74 Revised October 2012 VOUCHER LOG Department of Human Services Subsidy, Resource & Referral Program Provider Voucher Log Provider’s Name: Date Child(ren) Name Voucher Number Subsidy Amount Signature 75 Revised October 2012 21:2 CLIENT LETTER & FORMS Required letters and forms to be used by staff 21:2-A Application (system generated) 21:2-B Appointment Letters (Reg. & Summer Only) 21:2-C Case Exchange Request 21:2-D Change of Provider 21:2-E Change of Status 21:2-F Child Care Preliminary Application (English, Spanish & Summer) 21:2-G Child Care Verification 21:2-H Consent for the Release of Information 21:2-I Final Notice 21:2-J Income Verification 21:2-K Ineligibility Notice 21:2-L Notice of Pending Documents 21:2-M Notice of Subsidy Change 21:2-N Parent Agreement 21:2-O Paternity & Child Support 21:2-P Proxy 21:2-Q Recertification Notice 21:2-R Referrals (Jobs & Intake/Intervention) 21:2-S Transfer Request 21:2-T Verification of Support 21:2-U Voucher Appointment Card Replacement 21:2-V Voucher to be Void 76 Revised October 2012 77 Revised October 2012 78 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services APPOINTMENT LETTER Date:__________________________ Dear Applicant; Thank you for your interest in the Child Care and Regulatory Services program. An appointment has been scheduled for you on __________________at __________. You must bring with you all applicable documents from the list below to your appointment. 1. Birth Certificates (household) 2. Immunization card or Exemption letter (only child(ren) needing assistance). 3. Income Tax Return (current) if self-employed. 4. Income Verification (attached) completed & signed by your employer or HR office) & two last check stubs. 5. Letter of enrollment from school or training program (if applicable) 6. Paternity & Child Support documents or check stubs, if absent parent is not supporting, (A case must be filed at Paternity and Child Support if not supporting voluntarily). 7. Photo ID 8. Provider of choice. 9. Social Security Cards - (household) - optional 10. Support information from absent parent (letter must be notarized). Please make every effort to keep your appointment. Failure to keep the appointment will result in your name being immediately removed from our Waiting List. If you have any questions, please contact the office at phone number listed above. _________________________ Child Care Specialist – SR&R □ Knud Hansen Complex Bldg. A 1303 Hospital Ground – STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 79 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services SUMMER ONLY APPOINTMENT Date: ___________________________ Thank you for your interest in the summer assistance program. The Subsidy, Resource & Referral program will assist you for summer only. The following documents must be provided with your appointment. Income Verification (completed and signed by your employer or HR department) and last two check stubs; Birth Certificate(s) – household; Immunization or exemption letter; Photo Identification; Social Security Card(s) household - optional; Summer Camp Information Appointment Date:________________________at_____________ If you are unable to keep your scheduled appointment, please contact the office to be rescheduled. If you have any questions, you may contact the office at the phone number listed above. ____________________________ Child Care Specialist – SR&R □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 80 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services CASE EXCHANGE REQUEST I, _______________________________________________case #________________ authorize_________________________, as my temporary  permanent  , representative to conduct business to include recertify and sign documents and perform other duties on my behalf while I am away from the Virgin Islands, for the purpose listed below: ____ Attending School ____ Economic Reason ____ Medical Emergency ____ Military Duty ____ Other (specify) My authorized representative will provide a legal document and other documents required for eligibility determination in order to continue receiving child care assistance. _____________________________ Client Name & Date _____________________________ Child Care Specialist & Date □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 81 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services CHANGE IN PROVIDER TO BE COMPLETED BY CURRENT PROVIDER: NAME OF PROVIDER _______________________________________________________________ _______________________________________________________________ NAME OF CHILD(REN): _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ IS PARENT ACCOUNT CURRENT? YES ___________ NO _____________ WERE YOU NOTIFIED OF THE PARENT INTENT TO CHANGE?:_________DATE:____________ DIRECTOR SIGNATURE: _________________________________ DATE:_______________________ TO BE COMPLETED BY PARENT: NAME OF PARENT: ___________________________________________________________________ NAME OF NEW PROVIDER: ____________________________________________________________ WAS PROVIDER NOTIFIED OF YOUR INTENT TO CHANGE? ____________WHEN:___________ REASON FOR CHANGE: _______________________________________________________________ _______________________________________________________________ _________________________________________________________ DATE CHANGE WILL BE EFFECTIVE: ___________________________________________________ PARENT SIGNATURE: ________________________________ DATE: __________________________ TO BE VERIFIED – SR&R REPRESENTATIVE: ___________________________ DATE: ________ □ Knud Hansen Complex Bldg. A 1303 Hospital Ground. STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 82 Revised October 2012 CHANGE OF STATUS I______________________________________ am certifying the following changes: ________Change of employment. ________Currently disabled or on medical emergency. ________Currently on maternity or sick leave. ________Currently receiving child support payments. ________Family size increase or decrease. ________Has an additional job. ________Home phone or work phone. ________Increase income (wage change). ________Married or Divorce. ________Name change ________No longer working, attending school or training. ________Physical or mailing address. ________Receiving social security benefits. ________Residing with child(ren) father or mother. I hereby certify that the above information is correct and true. I understand that the information will be verified. I also understand that deliberate false information will result in a delay or disqualification of my child care subsidy. _____________________________ ________________________________ Client Signature & Date SR&R Representative & Date 83 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services Subsidy, Resource & Referral Program PRELIMINARY APPLICATION No.: ______ NAME: _____________________________________ FAMILY SIZE: _________ MAILING ADDRESS: ___________________________________________________ ____________________________________________________ TELEPHONE NOS.: _________________ _________________ ________________ NAME OF EMPLOYMENT, SCHOOL OR TRAINING PROGRAM: _______________________________________________________________________ _______________________________________________________________________ ARE YOU A TEEN PARENT?  YES  NO ANNUAL INCOME: $_____________ CHILD SUPPORT INCOME: $____________ NAME OF CHILD (REN) IN NEED OF SERVICE: ________________________________ DOB: ________________Special Needs (Y/N) ________________________________ DOB: ________________Special Needs (Y/N) ________________________________ DOB: ________________Special Needs (Y/N) Have you applied for or are you receiving child care services from any of the following? Head start Early Head start AmeriCorps Labor Military Other ______________________ __________________ Signature of Applicant Date If you are found eligible, you will be placed on the waiting list, upon the availability of funds; however, if you are found ineligible you will be notified. OFFICIAL USE ONLY  ELIGIBILE Completed  No longer interested  No Show INELIGIBLE Insufficient hours Not in a component Over qualify Other □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 84 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services FONDE DE DESARRAOLLO DEL CUIDADO DE DE NINOS USO PRELIMINAR Num.: ______ Nombre: ____________________________________ Asimiento de casa: ___________ Direccion de Envio: ____________________________________________________ ____________________________________________________ Numero de Telefono: :_________________ _________________ : _______________ Lugar de Empleo, Escuela o Programa de Entrenamiento: ________________________________________________________ : _______________________________________________________ PADRES SON ADOLESCENTES?  SI  NO Ingresos Anuales: $_____________ Manutencion de Menor: $______________ Nombre de Nino/Ninos: _________________ Fecha de Nac: ____________Con Necesidades Especiales (Si/No) ________________ Fecha de Nac: ____________Con Necesidades Especiales (Si/No) __________________ Fecha de Nac:____________Con Necesidades Especiales (Si/No) Algun dia uste a aplicado para ayudar en cuidado de ninos?  Head start Early Head start AmeriCorps Labor Military Other ______________________ __________________ Firma del Aspirante Fecha OCCRS/TJA 2010. If you are found eligible, you will be placed on the waiting list upon the availability of fund; however, if you are found ineligible you will be notified. PARA USO OFICIAL SOLOMENTE  Eligible Completed  No longer interested  No Show  Ineligible  Insufficient hours  Not in a component  Over qualify  Other □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 85 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services SUMMER ONLY PRELIMINARY APPLICATION No.: ______ NAME: _____________________________________ FAMILY SIZE: _________ MAILING ADDRESS: ___________________________________________________ ____________________________________________________ ____________________________________________________ TELEPHONE NOS.: _________________ _________________ ________________ NAME OF EMPLOYMENT, SCHOOL OR TRAINING PROGRAM: _______________________________________________ _______________________________________________ ANNUAL INCOME: $_____________ CHILD SUPPORT INCOME: $____________ NAME OF CHILD (REN) IN NEED OF SERVICE: _________________________________ DOB: _______________ Special Needs (Y/N) _________________________________ DOB: _______________Special Needs (Y/N) ______________________ __________________ Signature of Applicant Date OFFICIAL USE ONLY  ELIGIBILE Completed  No longer interested  No Show  INELIGIBLE  Insufficient hours  Not in a component  Over qualify  Other □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 86 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services CHILD CARE VERIFICATION DATE:_______________________________ To Whom It May Concern: This letter verifies that ______________________________, is/was receiving a monthly subsidy towards her/his child care expenses from the Subsidy, Resource & Referral program. Name of Child (ren) Provider Amount _______________________ ______________________ __________________ _______________________ ______________________ __________________ _______________________ ________________________ __________________ _______________________ ________________________ __________________ _______________________ _________________________ __________________ _______________________ __________________________ __________________ TOTAL __________________ Please contact the Subsidy, Resource & Referral program, at the phone number listed above, if you should need any additional information. _______________________________ Child Care Specialist - SR&R □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 87 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services CONSENT FOR THE RELEASE OF INFORMATION I, ___________________________________, hereby give consent to the Department of Human Services – SR&R program to disclose to another government agency or agencies (both federal and local) information I have given, or may give, concerning my family, when such disclosure is necessary and pertinent to the determination or confirmation of eligibility for me and/or members of my family to receive benefits or services from the Department of Human Services – SR&R program. I further consent to other government agencies, (both federal and local), disclosing to Department of Human Services – SR&R program, information concerning me and my family, when such disclosure is necessary and pertinent to the determination or confirmation of the eligibility for me and/or members of my family to receive benefits or services from the Department of Human Services – SR&R program. Any client receiving funding and later determined ineligible due to false information will have to repay the SR&R program according to the terms of the agreement provided by the Department. ________________________________ SR&R Representative Signature ________________________________ Client Signature ________________________________ Date □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 88 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services FINAL NOTICE Date:_________________________ Dear:_________________________ Thank you for your interest and/or participation in the Subsidy, Resource & Referral program, however since you have missed several rescheduled appointments your case is pending and will be closed if action is not taken. Please note: Since we are unable to provide you with any or further assistance, a final appointment have been scheduled for __________________________, however, failure to keep the appointment will result in your case being immediately close. We are again requesting the following required document(s) to complete your case: _______Birth Certificate(s) _______Immunization Card(s) or Exemption Letter _______Income Verification and/or two last check stubs _______School or training letter _______Support Documents _______Other However, if you are no longer interested in participating in the Subsidy, Resource & Referral program, please notify the office at the phone number listed above. _____________________________ Child Care Specialist – SR&R □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 89 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services INCOME VERIFICATION Employer: Please provide up-to-date employment information. Thank you. Employee Name: ________________________________________________________________ Mailing Address_________________________________________________________ Physical Address: ________________________________________________________ Name of Employer: _______________________________________________________ Employer Mailing Address: _______________________________________________ Employer Telephone Number: _____________________________________________ Employment Status: Permanent________ Part-time_________ Temporary ________ If temporary, give dates of employment contract: ________________________________ Date Employee Started: _____________ How many hours work per week___________ Annual Salary: $____________________ Hourly Rate: __________________________ Monthly Salary: $___________________ Date of last increase: ____________________ _______________________________ ____________________________ _____ Signature (Employer or Agent) Print Date ________________________________ Title □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 90 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services INELIGIBILITY NOTICE Date: ___________________________________ Dear: ___________________________________ This letter serves as a formal notification that as a result of the item(s) indicated below you are no longer eligible to receive a child care subsidy under the Subsidy, Resource & Referral program. ____ Case closed per your request ____ Currently not in working, going to school or attending a training program. ____ Failure to keep several appointments ____ Failure to report additional income ____ Insufficient hours (under mandated 30 hours per week). ____ Over qualification (based on income and family size) ____ Other _______________________________________________________________________ The changes are effective ________________________________________, however, if your current situation changes, you may reapply for assistance. You may contact us at the phone number listed above. ________________________ Client Signature - Date __________________________ Child Care Specialist - Date □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 91 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services NOTICE OF PENDING DOCUMENTS Date: ___________________________________ The following document(s) must be submitted to complete your Client File. ____ Birth Certificate(s) ____ Immunization Card(s) ____ Income Verification or check stubs ____ School or training enrollment letter ____ Support or Paternity & Support document(s) ____ Other _____________________________________________________ ______________________________________________________ Please submit the above pending documents to the Child Care Office at #6179 Est. Anna’s Hope, Christiansted, VI 00820. If you are unable to drop-off the documents you may email the document to: dora.maxwell@dhs.vi.gov Thank you! _____________________________ Child Care Specialist & Date □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 92 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services NOTICE OF SUBSIDY CHANGE Dear ______________________________ Please be advised that the subsidy amount will change effective _________________. For: ___________________increase/decrease from _____________to_____________. For: ___________________increase/decrease from _____________to_____________. For: ___________________increase/decrease from _____________to_____________. For: ___________________increase/decrease from _____________to_____________. As a result, you are responsible for the co-payment fee(s) to your provider in the amount of $__________, per child. Should you have any questions, please call contact the office, at the phone number listed above. Sincerely, Child Care Specialist – SR&R □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 93 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services PARENT/AGENCY AGREEMENT FOR RECEIVING CHILD CARE SUBSIDY Case # ________________ I ___________________________________________, hereby agree to receive child care assistance in the form of a voucher, for child care services under the Subsidy, Resource & Referral program. I authorize the agency to make payments for child care services to an approved licensed or registered provider of my choice. The voucher will be printed to the provider(s) for my child (ren), for a specific monthly amount(s), which I am eligible to receive. I understand that the subsidy I am eligible to receive is based on my income, family size, and the type of child care provider I choose for my child (ren). The subsidy amount available is based on the current maximum rates established by the Subsidy, Resource & Referral program. I understand that I will be notified of any changes in these amounts. I understand that the child’s parent will not be paid as caregivers for their own child (ren). In addition the Subsidy, Resource & Referral program will not provide payment to informal provider who resides in the same household of me and my child (ren). I understand that I am eligible to receive child care vouchers for a period of 6 months (or less) per child. I am responsible for co-payment (cost sharing) fees per month, per child (ren), to my provider. Further, I understand that I am also responsible for any other child care provider costs, in excess of the maximum subsidy amounts indicated on my child care subsidy agreement for the type of care I choose minus the co-payments and any other applicable fees which I am responsibility to pay directly to the child care provider. Based on the availability of funds, I will receive an eligible amount of child care benefits per child from the SR&R program; however, I am responsible for the co-payment and difference as follows: □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 94 Revised October 2012 Child__________________ Eligible Amount ________ Co-payment______ Difference______ Child__________________ Eligible Amount________ Co-payment______ Difference______ Child__________________ Eligible Amount________ Co-payment______ Difference______ Eligibility Period: Beginning:____________________________Ending:____________________________ I agree to provide proof of continued eligibility every 6 months (or less), by keeping my schedule recertification appointment(s). I agree to notify my child care provider(s) and the Subsidy, Resource & Referral program of any child care changes within the period of service in which it occurs. I understand that the subsidy and any future child care assistance funded by this program, for which I may be eligible, are contingent upon the availability of federal funds. I understand that I must notify the Subsidy, Resource & Referral program of any changes in my family circumstances, within 10 business days from the occurrence. I understand that failure to report income increase within 10 business days may result in an overpayment. I understand that if an overpayment occurs the subsidy amount will be adjusted in the following month, totaling the amount of month(s) overpaid. I understand that the Subsidy, Resource & Referral program is authorized to issue voucher to only one provider for a specific period of services, but I may choose a different provider for a different period of time within the month. I have read this Agreement to receive child care assistance and understand and accept its terms. I understand that failure to comply with the terms of this Agreement may result in the delay, suspension or termination of my child care assistance. I have received a copy of this Agreement and understand my right to file a written complaint and/or request a fair hearing. _________________________________ Print: (Name of Parent) _________________________________ Client Signature & Date _________________________________ Child Care Specialist & Date 95 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services PATERNITY AND CHILD SUPPORT VERIFICATION Please provide the following information. Thank You. This is to verify that ____________________________SS#______________has established a case at Paternity & Child Support against _________________________on behalf of the following child (ren). _______________________________________ _______________________________________ _______________________________________ o This client receives $ _________________________ per week / per month. o This client has established a case; however, has not received any monies to date. Completed by: _____________________________________________ _________ Paternity and Child Support Representative Date Received by: __________________________________________ _________ SR&R Representative Date □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 96 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services PROXY I hereby authorize, _______________________________________, as the person to sign for and receive vouchers assigned to me, for child care services, under the Subsidy, Resource & Referral program. ____________________________ Signature of Client _______________________________ Date _______________________________ Proxy Signature _______________________________ Proxy Mailing Address ________________________________ Proxy Home Address ________________________________ Proxy Relationship to Child ________________________________ Proxy Telephone Numbers Home: _________Work: ___________ OCCRS Office Use Only ____________________________________ SR&R Representative ____________________________________ Date NOTE: Proxy is not authorized to sign vouchers. This document gives you the permission to receive and forward the voucher to client. □ 97 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services RECERTIFICATION NOTICE Date:_________________________ Dear___________________________: Your case is schedule for recertification on ____________________________, at __________. In order to complete the recertification process, please submit all applicable documents from the list below:  Affidavit of Legal Guardianship or a Power of Attorney if you are not the parent.  Birth Certificate(s) (for new family members.)  Death Certificate if parent is deceased.  Documentation from the Justice System, if a parent is incarcerated.  Immunizations card(s) or Exemption Letter (updated).  Income tax return (current) if self-employed.  Income Verification (attached) completed and signed by your employer or HR office along with your two (2) last check stubs.  If married or not married but living together both income must be submitted  Married clients who are legally separated must provide proof of legal separation.  School or training program enrollment letter (if applicable)  Social Security Card(s) optional – (for new family members.)  Support documents:Voluntary Statement for Verification of Child Support (attached) Clients receiving assistance through Paternity and Child Support are required to provide updated status of case. However, parents who are not receiving support for their child(ren) are required to file a case at the Office of Paternity and Child Support. If you are unable to keep your scheduled appointment please contact the office at the phone number listed above to reschedule. PLEASE NOTE: Proxies are not allowed to complete the recertification process and clients who miss their appointments; will not be issued vouchers until their case is completed. Please make every effort keep your appointment in the month that it is scheduled. Thank you. _________________________ Child Care Specialist 98 Revised October 2012 JOBS PROGRAM/FINANCIAL PROGRAMS DIVISION INTER-OFFICE CHILD CARE REFERRAL FORMS  New Case  Continued Case  Withdrawal/Termination Notification Section A: Agency Information (To be completed by JOBS ETO) RE: CHILD CARE REQUEST DATE: FROM: TO: PHONE#: PHONE#: FAX#: FAX#: E-MAIL: E-MAIL: Request Detail: Child Care Assistance is requested for the following participant who will be placed in a work activity. Please note participant’s schedule and start date. Section B: Participant Information (To be completed by JOBS ETO) JOBS Participant: JOBS Case Number: Address: Date of Birth: Telephone #1: Telephone #2: Children Referred for Child- Care: #1: DOB: #2: DOB: #3: DOB: #4 DOB: #5: DOB: #6: DOB: Income: TANF: Food Stamp: Work Activity Schedule: Child Care Start Date: Child Care End Date: Section C: Placement Confirmation to be completed by Childcare staff and transmitted to JOB Date of Receipt of this Request: Child Care Case Name of Child Care Provider(s): #1 #2 Date(s) of Participant’s Appointment: Cost ($ Amount) Per Month: Date of Child Care Placement: Section D: Termination Request/Notification (To be completed as necessary) To: From: Date of Termination: Reason for Termination: □ excess resources □ insufficient hours □ not in a work activity □ failure to comply B: Staff persons of each unit have an obligation to inform members of the other unit of known 99 Revised October 2012 SUBSIDY, RESOURCE & REFERRAL INTER-DEPARTMENTAL REFERRAL FORM HEAD OF HOUSEHOLD REQUESTING ASSISTANCE 1 Reason for Needing Care: □ Teen □ Protective Services □ Foster Care □ Intake □ Special Needs □ Summer □ Juvenile □Other : 2 Name of: □ Parent □ Guardian □ Foster Parent □Other Date of Birth: 3 Social Security Number: Family Size: 4 Physical Address: 5 Mailing Address: Phone Numbers: (H) (W) (C) 6 Single Parent: □ Yes □ No if no, complete numbers 7-8 7 Name of other financially responsible adult residing in the household: □ Spouse □ Child’s Father □ Other Date of Birth: 8 Social Security Number: HOUSEHOLD INCOME SOURCES AMOUNT(S) 9 □Employment □Self Employment □Education/Training □Yes □ No 10 Child Support: □Yes □ No 11 Tanf: □Yes □ No 12 Other Income: □Yes □ No 13 Total Yearly Family Income for Determining Eligibility: $ Provider(s) 14 Provider(s) of Choice: □ Selected □ None Selected 15 Date child care assistance is needed: Length of service Dependent Children Needing Child Care Assistance Children Provider Date of Birth Special Needs 1. □Yes □ No 2. □Yes □ No 3. □Yes □ No 4. □Yes □ No 5. □Yes □ No 6. □Yes □ No Referred By: Date: (Please attach supporting documents) 100 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services TRANSFER REQUEST I, _________________________________residing on the island of ____________________, am requesting that my case be transferred to the island of__________________________, effective_________________________. The provider of my choice will be ________________________and my child will be enrolled effective______________________________. I will be providing updated information regarding my changes, within the allowable grace period to continue receiving services. _____________________________ Client Signature & Date _____________________________ SR&R Representative & Date □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 101 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services STATEMENT FOR VERIFICATION OF CHILD SUPPORT I, _________________________, certify that, I provide $______________ Please Print for support of my child(ren). ____ Weekly ____ Bi-Weekly ___ Monthly ___ Bi-Monthly Name of Child or Children: _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ ___________________ Signature Date Case Name: ___________________ Case No: ____________________ Case Worker: ___________________ Subscribed and sworn to before me by ________________________this day of__________________20____ _____________________________ Notary Public □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 102 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services STATEMENT FOR VERIFICATION OF CHILD SUPPORT I, ___________________________, certify that I receive $____________ for support of my child(ren) from ____________________________. Please Print ____ Weekly ____ Bi-Weekly ___ Monthly ___ Bi-Monthly Name of Child or Children: __________________________________ __________________________________ __________________________________ __________________________________ _________________ Signature Date Case Name: ___________________ Case No: ____________________ Case Worker: ___________________ Subscribed and sworn to before me by ________________________this day of__________________20____ _____________________________ Notary Public □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 103 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services VOUCHER APPOINTMENT CARD REPLACEMENT I, _________________________________ hereby certify that I have lost or misplaced the Subsidy, Resource & Referral subsidy voucher appointment card and I am requesting a replacement. ____________________________ Client Signature ____________________________ Date □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 104 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services VOUCHER TO BE VOIDED I _____________________________________, am requesting your assistance in (Client) voiding the following voucher: Child Name : _______________________________________ Voucher # : _______________________________________ Provider : ______________________________________ The following reason justifies the need for voiding the voucher: □ Age appropriate - □ infant □ preschool □ after school □ Change of income □ Change of provider □ Child did not attend □ Facility Closed □ Over Payment □ Provider increase fees □ Under payment □ Other_______________________________________________ ____________________________ Client Signature & Date ____________________________ Processing Coordinator & Date ____________________________ Program Director & Date □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4763 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 105 Revised October 2012 21:3 PROVIDER LETTERS & FORMS Required letters and forms to be used by staff 21:3-A ACH/Electronic Payment Vendor Request Form (Direct Deposit) 21:3-B Affidavit of Lost Checks 21:3-C Authorization for the Release of Check 21:3-D Informal Care Home Inspection & Interview 21:3-E Informal Provider Notice 21:3-F Inspection Check List 21:3-G Inspection Notice 21:3-H Pending Letter 21:3-I Provider Agreement – Authorization for Payment 21:3-J Provider Cover Letter (renewing payment agreement) 21:3-K Provider Letter (new provider) 21:3-L Provider Notification 21:3-M Provider Verification 21:3-N Request for Inspection 106 Revised October 2012 107 Revised October 2012 108 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services AUTHORIZATION FOR THE RELEASE OF CHECK I hereby authorize, _______________________________________, as the person to sign for and receive check assigned to me, for child care services, under the Subsidy, Resource & Referral program. ______________________________________ Signature of Provider ______________________________________ Date ______________________________________ Authorized Representative Signature ______________________________________ Authorized Representative - Mailing Address ______________________________________ Authorized Representative - Home Address ______________________________________ Relationship to Provider Home: Work: _ ___ Authorized Representative - Telephone Numbers OCCRS Office Use Only ____________________________________ SR&R Representative ____________________________________ Date NOTE: Authorized Representative is not authorized to sign the check. This document gives you the permission to receive and forward check to provider. □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 109 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services INFORMAL CARE HOME INSPECTION & INTERVIEW Date of Visit_____________ Name of Provider:_________________________________________________________ Physical Address: _________________________________________________________ Mailing Address:__________________________________________________________ Physical Address care will be provided:_________________________________________ Is Provider over 18 years Yes  No  Name of participant care is being provided for:__________________________________ Relationship to participant: Parent  Sibling  Friend  Other (specify)_______________________ Relationship to child(ren) being cared for: Grandparent  Sibling  Friend  Other (specify)_______________________ List the child(ren) care will be provided for: Child’s Name D.O.B. Gender ____________________________ _________________ ______________ ____________________________ _________________ ______________ ____________________________ _________________ ______________ ____________________________ _________________ ______________ ____________________________ _________________ ______________ □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 110 Revised October 2012 Page:2 PART A. HOME INSPECTION CHECKLIST Part B. INTERVIEW COMMENTS PHYSICAL ENVIRONMENT 1. Adequate floor space.   2. Clean surface in good repair.   3. Adequate ventilation.   4. Running warm and cold water.   5. Accessible working indoor toilets.   6. Sturdy, safe, non- toxic, easy to clean, free of hazards, indoor and outdoor equipment.   7. Sufficient furniture and equipment for children.   8. Working telephone in home.   FIRE SAFETY 1. Working smoke detector.   2. Lockable interior doors which can unlock from outside.   3. Protected heating or cooling ventilated devices   4. Unobstructed stairways, hallways or exit   5.Good condition of electrical cords   GENERAL SAFETY/SANITATION 1. No hazard present with home and furnishings   2. All toxic substance out of reach   PLEASE INSPECT THE HOME AND INDICATE THE COMPLIANCE STATUS USING THE CODES: (1) In compliance (2) Technical assistance to be provided by program. (3) Not incompliance 111 Revised October 2012 3. Clearly marked glass doors at child level   4. Non-permanent barriers on stairs, ramps, balconies, porches and elevated play areas.   5. Covered electrical outlets.   6. Available working flashlight.   7. Adequate safe outdoor play area adjacent to or within walking distance of the home.   8. Properly covered garbage stored and emptied.   9. Available first aid supplies.   10. Washable or disposable individual towels and washcloths.   PROGRAM 1. Adequate safety toys, play equipment and creative materials for ages, interests, and number of children in care.   REST AND SLEEP 1. Clean safe area for daily rest/sleep for each child according to needs.   2. Available drinking water.   3. Are there children under 18 months or non-walkers in care? Yes  No  (Go To Part B) (a) If Yes, do they sleep in a crib, playpen, cot, bed with rails, or floor mat 1” thick? Yes  No  (Go To Part B) (b) Are the crib and playpen slats no more than two and three eight inches apart? Yes  No  (c) Are wet sheets, bed covering changed? Yes  No  Page: 4 112 Revised October 2012 PART B. INTERVIEW Account for all other persons who may come in contact with the enrolled children in your care. PLEASE INDICATE ALL OTHER PERSONS (ADULTS & CHILDREN) RESIDING IN THE HOME, WHETHER THEY WILL BE (ARE) AT HOME DURING THE TIME THE ENROLLED CHILDREN ARE IN YOUR CARE, AND THE EXTENT OF CONTACT EACH WILL HAVE WITH THE CHILDREN USING THE CODES BELOW. RELATIONSHIP OF OTHERS IN HOME TO CAREGIVER (COL2) GENDER (COL 3) AT HOME DURING CARE (COL 5) EXTENT OF CONTACT (COL 6) (1) Spouse (1) Male (1) At home (1) No contact (2) Son/Daughter (2) Female (2) Not a home (2) Some contact (3) Brother/Sister (3) Frequent contact (4) Relative other than above (5) Friends (6) Other (specify) NAME COL 2 COL 3 BIRTHDATE COL 5 COL 6 1. 2. 3. 4. 5. 6. 1. Language spoken in home? 2. How long can you provide care? Months Weeks 3. How often can you provide care? Full time Part time 4. Will you be able to provide care during holiday? (a) If Yes, how often can you provide care? Yes  No  Full time Part time 5. Will you be able to provide care during summers? (a) If Yes, how often can you provide care? Yes  No  Full time Part time 6. Have you ever been convicted of a crime? (a) If yes, explain? Yes  No  113 Revised October 2012 Note: EVIDENCE OF CONVICTION OF A CRIME, IN ITSELF, SHALL NOT AUTOMATICALLY PRECLUDE AN INDIVIDUAL FROM SERVING AS A CAREGIVER. SUCH DETERMINATION SHALL BE MADE ON A CASE BY CASE BASIS. Page: 5 Complete NCIC FORMS, if indicated. 7. Do you have any illness or medical condition that would prevent or limit you from providing child care services? If Yes, Explain: Yes  No  8. Have you had other experiences working with children? Describe: Yes  No  9. What methods of discipline will you use with the children in your care? 1. Set Limits 2. Allow time out 3. Redirect Activities 4. Talk to child 5 Other 10. How will you handle medical emergencies if you or children in your care should get sick during the hours child care is being provided? 1. Call parent 2. Call Emergency Medical Technician 3. Take child to doctor 4. Take child to hospital emergency room 5. Other 11. Who, other than the child parent, will be able to pick-up the child at the end of the day? 1. Spouse 2. Child siblings 3. Child grandparent 4. Other relative to child 5. Friend of child parents 6. Other (specify) 12. Do you have telephone numbers in order to contact the above person(s)? Yes  No  13. What arrangements have been made to provide nutritious meals to the child/children in your care? 1. All meals are provided by parents 2. All meals are provide by caregiver 3. Some meals are provided by caregiver and some by parent. 114 Revised October 2012 Page: 6 PART C. OBSERVATIONS OF THE EVALUATOR 14. Describe the applicant home management skills in relation to assessing their home. 15. Have you observed any condition or situation that would cause you to deny this application? If yes, please explain. 16. Is this an initial inspection of the home? (1) Yes  (2) No  If YES, what is the disposition of this application? Approved__________ Denied ___________ Reasons:_____________________________________________ If APPROVED, has emergency card been provided? (1) Yes (2) No (3) Not applicable to this program _________________________________________ __________________ Evaluator’s Signature: Date: 115 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services INFORMAL PROVIDER NOTICE Date: _________________________ Dear Applicant: Thank you for your interest in the Subsidy, Resource & Referral program. Your choice of informal provider has been approved ___ disapproved ___ to provide child care services with the Subsidy, Resource & Referral program, effective _________________. If you are in need of any further assistance, please contact the Subsidy, Resource & Referral program, at the phone number listed above. Sincerely, SR&R Representative □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 116 Revised October 2012 INSPECTION CHECK LIST _______More than two (2) unrelated children are in care without a license. _______There is not a working telephone in the home. _______Emergency numbers are not posted. _______The children are not adequately supervised. _______The child care provider smokes or drinks in the presence of the child(ren). _______No smoke detector present. _______The kitchen or eating are is unsanitary. _______The bathroom is unsanitary. _______Rodents or vermin are present. _______The floor space is not adequate for the number of child(ren). _______The outdoor space is unsafe or unsanitary. _______The home or furnishings present a hazard to the child(ren). _______Toxic substances are not placed out of reach of child(ren). _______Electrical outlets are uncovered and accessible to the child(ren). _______The garbage is uncovered or improperly stored. _______The sleep area is unclean or unsafe. _______Abusive disciplinary methods observed. _______Inaccurate record keeping on attendance certificate was identified and found Fraudulent. 117 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services INSPECTION NOTICE Date:_______________________ Dear Provider: The Subsidy, Resource & Referral program would like to inform you that your home inspection has been approved ___ disapproved ___, effective _______________________________to care for: Child: __________________________________Eligible Amount:_______________ Child: __________________________________ Eligible Amount:_______________ Child: __________________________________Eligible Amount:_______________ Child: __________________________________Eligible Amount:_______________ Thanks for your willingness to provide child care services. If you have any questions, please feel free to contact the office at the phone number listed above. Sincerely, SR&R Representative □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 118 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services PROVIDER AGREEMENT – AUTHORIZATION FOR PAYMENT THIS AGREEMENT is entered into this _________ day of ____________________, ________ by and between the Government of the U. S. Virgin Islands, Department of Human Services (hereinafter referred to as “Human Services” and _________________ (hereinafter referred to as “Provider”). This Agreement shall commence on September 1, 20 ___ and shall terminate on August 31, 20____. It shall become effective upon the date of final execution by all parties. PROVIDER INFORMATION Provider Business Name:_________________________________________________ Provider Physical Address: _______________________________________________ Provider Mailing Address: _______________________________________________ Telephone #: ( ) __________-Facility (_____)____________________ - Home (______) ____________________– Cell (_______)______________ - Emergency Tax ID Number:_________________________________________________________ Social Security Number or EIN: _____________________________________________ TYPE OF CHILD CARE PROVIDER ______ A. Licensed Child Care Center E. Group Day Care ______ B. Licensed Family Day Care Home _______Home Based ______ C. Summer Camp/Kid’s Club _______Center Based ______ D. Before and/or After School Program F. Informal Care ____ __ Relative ______ Non- Relative □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 119 Revised October 2012 Child Care Centers, School Age Child Care and Summer Camps must attach a copy of their rate schedule or a handbook listing their published rates. PROVIDER REGISTRATION – DATA SHEET US Citizenship: _____ ____ Yes __________ No Visa/Naturalization Number: _______________________________________________ Hours of operation: ______________ 1 – 29 Hours ________ _____ Over 30 hours Number of Staff Members: ____ _______ 1–3 ___________ 4-6 _____________ 7 or more Spoken Language: ________ _______English ___________ Spanish ________French Licensed Facility: ________________ Yes ______ _______ No After-School Provider: ____________ Yes _____________ No AGES SERVED _____________ All ______________ 0-24 _____________ 25 months – 4 years ______________ 5-13 years FEE SCHEDULE (MONTHLY) Infant (0-1) $ __________ Toddlers (1-2) $ ___ ___________ Pre-school (3-4 yrs) $ _________ After-school (5-12) $ ________ Summer Camp (3-12 yrs) $ ___________ Special Needs (0-19 yrs) $ __________ IN-HOME PROVIDER ONLY Name of parent serving: ______________________________________________________________________________ Name(s) of Child(ren) being served: ______________________________________________________________________________ ______________________________________________________________________________ 120 Revised October 2012 PROVIDER AGREEMENT-AUTHORIZATION FOR PAYMENT I, hereby, certify and agree to accept the child(ren) for whom the Department of Human Services will pay a subsidy for child care services determined. The parent will be responsible for the payment of a co-pay fee. I understand that child care cost incurred which exceeds the subsidized amount is the responsibility of the parent(s), to be paid by the parent(s) and collected by me. ___________ Initial I understand that I am responsible for the timely submittal of monthly vouchers which will serve as a bill for services and an attendance report for child care services rendered. I agree that these vouchers will be submitted, together with an Invoice to the Department of Human Services, Subsidy, Resource & Referral Program no later than the 5th day of the month following the current month of service. ___________ Initial I understand that my payments for services may be jeopardized or delayed if attendance records are not accurate or if a voucher is submitted later than the 5th day of the month following the current month of service. I understand that my payment for services will be based on the actual attendance of the child(ren) named. ___________ Initial I understand that I must provide at least fourteen (14) calendar days’ notification to the Department of Human Services – SR&R and the family prior to my intent to terminate child care services to the family. ___________ Initial I understand that prospective payment made by the Department of Human Services may be recouped by the Department if the level of service requires this and/or if I terminate a child without proper notification. I agree to repay the Agency any funds designated for recoupment. ___________ Initial I certify that I have informed the parent of my policy to ensure parental access while the eligible child(ren) are in my care. ___________ Initial If the type of care I provide is considered informal day care or home based group day care, I understand that a health and safety inspection of my home and an interview must be successfully completed by the Department of Human Services before payment for services can be authorized. I further agree to periodic “routine” inspections announced or unannounced. ___________ Initial I agree to immediately notify the Department of Human Services of serious occurrence or emergency, including but not limited to: (a) fire; (b) death of a child(ren) or caregiver; (c) serious accident or injury; (d) detection or presence of any serious communicable disease(s); (e) unusual or recurring absence of a child; and (f) alleged abuse (physical or sexual). __________ Initial 121 Revised October 2012 I understand and hereby agree that no person shall be excluded from participating in, be denied the proceeds of or be subject to discrimination in the performance of this Agreement on account of race, creed, color, sex, religion, disability or national origin. ______________ Initial I understand and hereby warrant that I shall not, with respect to this Contract, make or present any claim upon or against the Government of the Virgin Islands, or any officer, department, board, commission, or other agency thereof, knowing such claim to be false, fictitious, or fraudulent. I acknowledge that making such a false, fictitious, or fraudulent claim is an offense under Virgin Islands law. _____________ Initial I acknowledge that this Agreement is funded, in whole or in part, by federal funds. Contractor warrants that it shall not, with respect to this Contract, make, or present any claim knowing such claim to be false, fictitious, or fraudulent. Contractor acknowledges that making such a false, fictitious, or fraudulent claim is a federal offense. _____________ Initial By execution of this Agreement, I hereby certify that I am eligible to receive grant awards using federally appropriated funds and that I have not been suspended or debarred from entering into contracts or agreements with any federal agency. In the event that I misrepresent my eligibility to receive grant awards using federal funds, I agree that I shall not be entitled to payment for any work performed under this Agreement and that I will promptly reimburse the Government of the Virgin Islands for any progress payments heretofore made. ______________ Initial I have read this Agreement and understand and accept the terms stated. I understand that failure to comply with the terms of this Agreement may result in delayed payment or nonpayment for services rendered. _______________ Initial ______________________________ ___________________ _____________ (Print) Name of Provider Witness Date ______________________________ ____________________ _____________ (Print) Commissioner Witness Date Department of Human Services _______________________________ _____________________ ____________ (Print) Commissioner Witness Date Department of Property & Procurement 122 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services Date:________________________ Dear Provider, As the 20______- 20______school year approaches, the Subsidy, Resource & Referral program request that the attached Provider Agreement – Authorization Payment forms (3 typed originals) be completed, as your current agreement expires on August 31. In addition, please attach a copy of your rate schedule or handbook listing your published rates, current license, resolution, affidavit (FFN) and a list of your operational schedule or school calendar. Please complete the form thoroughly, sign and return to the office by _________________20________. Thank you for your usual cooperation. Sincerely, SR&R Representative □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 123 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services Date_________________________________ Dear Provider, Thank you for your interest in the Subsidy, Resource & Referral program, by participating in the program, your participating parents may be financially assisted with payments, for their child care services provided by your facility. To participate in the program, you are required to complete and provide the following documents: Provider Agreement - Authorization for Payment Fee Schedule Operational Schedule or School Calendar Affidavit Resolution W-9 ACH/Electronic Payments Vendor Request Form (Direct Deposit), if approved. If you have any questions, please contact the office at the phone number listed above. Your participation in the program is greatly appreciated. Thank you. _____________________________ SR&R Representative □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4763 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 124 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services PROVIDER NOTIFICATION Date: ___________________________________ Dear: ___________________________________ This letter serves as a formal notification that, as a result of the item(s) indicated below, you are no longer eligible to participate in receiving child care subsidy under the Subsidy, Resource & Referral program. ____ Expired Provider Agreement – Authorization for payment ____ Facility closed ____ Failure to submit documents ____ Program violation ____ Provider not license or license expired ____ Other _______________________________________________________________________ The changes are effective ________________________________________, if your current situation changes, you may reapply to participate in the Subsidy, Resource & Referral program. _________________________ Client Signature - Date __________________________ SR&R Representative - Date □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 125 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services DATE___________________________________ Dear Provider, Thank you for your participation in the Subsidy, Resource & Referral program. We have previously notified you of pending documents necessary to complete your participation or payment process. To date, we have not received your document(s). Your participation status in the Subsidy, Resource & Referral program is pending, as we are currently unable to continue processing your application or payment. Therefore, we are again requesting the following document(s): _____ Affidavit _____Attendance Certificate _____Direct Deposit Form _____Fee Schedule _____Invoice _____Operational Schedule _____Provider Agreement-Authorization for Payment _____Resolution _____Vouchers _____W-9 _____Other_______________________________________ Please note, failure to provide the required document(s) may delay and compromise your participation in the child care program. To avoid any further delays, please submit the pending document(s) by _______________________________. Sincerely, SR&R Representative □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 126 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services PROVIDER VERIFICATION DATE:_____________________________________ To Whom It May Concern: This letter certifies that ______________________________is/was receiving _____________ a month from the Subsidy, Resource & Referral program, for providing child care services for _______________________________. If you should need any further information, please contact me at the phone numbers listed above. Sincerely, SR&R Representative □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 127 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services REQUEST FOR INSPECTION PROVIDER INFORMATION Name:___________________________________________________________ Physical Address: _________________________________________________ Mailing Address:__________________________________________________ Telephone #: (_____)__________-Home (_____)___________________- Cell (_______)______________ - Emergency Name of parent requesting care: ______________________________________________________________________________ Name(s) of child(ren) needing care: ______________________________________________________________________________ ______________________________________________________________________________ TYPE OF CARE: A. Relationship to child (ren): ____________________________ □ Relative □ Non- Relative B. Is care being provided in the same home of the client and/or child (ren)? □ Yes □ No C. Place care will be provided? □ Provider home □ Child home □ Other (specify)_____________________ □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 128 Revised October 2012 I understand that I must be at least 18 years and cannot be residing in the same household of the parent and/or child(ren) for whom the Department of Human Services will conduct the inspection. I understand that I will be notified prior to the inspection. I understand that the inspection may be delayed if I am not available or I have not completed or provided all of the requirements necessary to complete the process. I understand that the type of care I provide is considered informal day care or home based group day care; I understand that a health and safety inspection of my home and an interview must be successfully completed by the Department of Human Services before payment for services can be authorized. I further agree to periodic “routine” inspections announced or unannounced. I have read this Agreement and understand and accept the terms stated. I understand that failure to comply with the terms of this Agreement may result in a delay or termination of the inspection. ______________________________ Name of Provider (Print) ______________________________ Signature ______________________________ Date 129 Revised October 2012 21:4 OTHER LETTERS & FORMS All require letters and forms to be used for either a client or a provider. 21:4-A Affidavit of Lost Voucher 21:4-B Complaint 21:4-C Repayment Agreement 130 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services AFFIDAVIT OF LOST VOUCHER I, _________________________________hereby certify that I have lost or (Client or Provider) misplaced the child care subsidy voucher, and I am requesting a replacement voucher(s) to cover the child care cost for the month of: ______________________, which was made payable to: ________________________________________, for the child (ren) (Provider name) and amount listed below: Name: __________________________________Amount_________________ Name: __________________________________Amount_________________ Name: __________________________________Amount_________________ Name: __________________________________Amount_________________ ____________________________ Signature ____________________________ Date Subscribed and sworn to before me by ________________________this day of__________________20____ _____________________________ Notary Public □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 131 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services CHILD CARE COMPLAINT Name of Complainant: Received Date: (month, day, year) Time received: Address): Received By: : (District, zip): Nature of Complaint: Telephone number: Assigned to: Relationship to provider: Date: Type of Provider: □ After School □ Day Care Center □ Family Home □ Group Home □ Informal Provide □ Residential Home □ Summer Camp Detail Extract of Complaint COMPLAINT DETAILS: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ OTHERS HAVING KNOWLEDGE OF INCIDENT:____________________________________________________________________________ ______________________________________________________________________________________ DATE OPERATOR NOTIFIED OF INVESTGATION: ______________________________________________________________________________________ ______________________________________________________________________________________ DATE OF INVESTIGATION AND FINDINGS: ______________________________________________________________________________________ ______________________________________________________________________________________ ACTION TAKEN OR RECOMMENDED: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Reviewed by: Assigned to: Date Reviewed (month, day, year Date Due (month, day, year Date Received (month, day, year) □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 132 Revised October 2012 Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services REPAYMENT AGREEMENT CLIENT NAME:______________________________CASE #:____________________ PROVIDER NAME:___________________________FACILITY__________________ ADDRESS___________________________________STATE_________ZIP_________ AMOUNT OVERPAID:___________________ Above acknowledges being in receipt of Subsidy, Resource & Referral (SR&R) services/benefits and/or overpayments from the Department of Human Services. The undersigned agrees to repay said overpayment. Total owed is $________________ and monthly payments are $___________________. MONEY ORDER SHOULD BE MADE PAYABLE TO: Department of Human Services Knud Hansen Complex, Bldg. A 1303 Hospital Ground St. Thomas, V.I. 00802 Said payments are to continue until the entire sum is fully paid. Upon default in the payment of any installment due, the entire unpaid amount shall, at the option of the Department of Human Services, become due and payable immediately without notice of nonpayment or demand for payment and the entire indebtedness may be collected by appropriate proceedings. (A copy of this agreement will be submitted with the payment). ______________________________________ _____________________________ SIGNATURE DATE PRINTED NAME OF PAYER OFFICIAL USE ONLY $_________________Payment in full $_________________Partial Monthly Payment $_________________Monthly Payments Effective_____________ OFFICIAL USE ONLY $_________________Payment in full $_________________Partial Monthly Payment $_________________Monthly Payments Effective_____________ □ Knud Hansen Complex Bldg. A 1303 Hospital Ground, STE. 1 St. Thomas, VI 00802-6722 Phone: (340)774-0930 Ext: 4189 or 4186 Fax: (340)774-4673 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Ext: 2115 or 2138 Fax: (340)718-9763 133 Revised October 2012 SECTION 22 APPENDIX All sample documents required for the program. 22:1 Appointment Card 22:2 Attendance Certificate 22:3 Brochures 22:4 Invoice 22:5 Monthly Report (CCC) 22:6 Promissory Note 22:7 Resolution & Affidavit (license & registered providers) 22:8 Voucher 22:9 W-2 134 Revised October 2012 APPOINTMENT CARD Department of Human Services 135 Revised October 2012 APPOINTMENT CARD - BACK 136 Revised October 2012 ATTENDANCE CERTIFICATE PROVIDER BROCHURE 137 Revised October 2012 138 Revised October 2012 PROVIDER BROCHURE – BACK 139 Revised October 2012 PARENT BROCHURE 140 Revised October 2012 PARENT BROCHURE-BACK 141 Revised October 2012 SAMPLE INVOICE CENTER LETTER HEAD DATE:____________________ Name of Center: _______________________________ Provider Name: _______________________________ Address: _______________________________ Invoice Number: _______________________________ (Different number assigned monthly) Child’s Name: Amount: 1. Jane Doe $300.00 2. John Doe $300.00 Number of Vouchers: Amount: $_______________________________ Signature: ________________________________ 142 Revised October 2012 MONTHLY REPORT 143 Revised October 2012 SAMPLE PROMISSORY NOTE I, ____________________________, parent/provider of ________________________, a participant in the Subsidy, Resource & Referral program, agree that there has been overpayment in the amount of $_________________________ for the period _____________________________ to _________________________. I hereby agree to liquidate this amount by making ______________________monthly installments of $_____________, beginning________________and ending_________________________. I understand that only money orders payable to Department of Human Services will be accepted. I agree to make the payments by the _____________________of each month and any default of ten (10) days, will require immediate intervention by the Attorney General’s Office. ___________________________ ____________________ Signature Date Subscribed and sworn before me this_________day of___________ 20_____. _____________________________ Notary Public 144 Revised October 2012 Sample Affidavit of Jane Provider Name: Jane Provider Occupation: Child Care Provider or Director I, Jane Provider, swear or affirm: 1. I am an adult, residing in St. Thomas, U.S. Virgin Islands. 2. I provide child care services and have agreed to participate in the Department of Human Services (DHS) Subsidy, Resource & Referral (SR&R) Program. 3. I understand as a participating Child Care Provider that I must abide by the U.S. Department of Health and Human Services-Administration of Children and Families CCDF Law Sec. 658E(2) Policies and Procedures-(A) Parental choice of providers and Section 658P which defines eligible providers. 4. I confirm that I will only charge the SR&R program for eligible children and that these children must live in a separate household and not reside in my home. 5. I also certify that I am eligible to receive grants, contracts and other compensation derived from federally appropriated funds and that I have not been suspended or debarred from entering into contracts with any federal agency. I SWEAR OR AFFIRM THAT THE ABOVE AND FOREGOING REPRESENTATIONS ARE TRUE AND CORRECT TO THE BEST OF MY INFORMATION, KNOWLEDGE, AND BELIEF. ______________________ _____________________________ Date Jane Provider U.S. VIRGIN ISLANDS I, the undersigned Notary Public, do hereby affirm that Jane Provider personally appeared before me on the ___________day of ___________ 201__, and signed the above Affidavit as his/her free and voluntary act and deed. 145 Revised October 2012 Sample LEGAL TRADE NAME OF BUSINESS ADDRESS Phone/Fax CERTIFICATE OF RESOLUTION LEGAL TRADE NAME OF BUSINESS A Virgin Islands Professional Sole Proprietorship The undersigned, SOLE PROPRIETOR’S NAME, certifies that I am doing business as a sole proprietor under the name of LEGAL TRADE NAME OF BUSINESS and certify to the Government of the Virgin Islands, (“The Government”) that the sole proprietorship is, and all times to which this resolution is relevant was duly qualified and in good standing under the laws of the Territory of the United States Virgin Islands and that the following resolution was duly adopted on the ______day of_______. RESOLVED, that SOLE PROPIERTOR’S NAME is authorized to execute and deliver a contract between the sole proprietorship and the Government under the terms of which the sole proprietorship shall perform a contract services (the “Contract”). RESOLVED FURTHER, that SOLE PROPRIETOR’S NAME, Director/Owner of LEGAL TRADE NAME OF BUSINESS, is hereby authorized to execute and deliver the Contract and any other related documents to the authorized agent of the Government, which may be required or requested by the Government. IN WITNESS WHEREOF, I have hereunto affixed my signature of the Sole Proprietorship on this _______day of ________. ________________________________________ SOLE PROPRIETOR’S NAME, Director/Owner 146 Revised October 2012 VOUCHER 147 Revised October 2012 W-9