An Application Packet (Page 6 of 14) in pdf

Parent Acknowledgement Form

Certification Statement

I UNDERSTAND my

Rights and Responsibilities (Page 6-14 in Parent Handbook).

SECTION IV

I HEREBY CERTIFY under penalty of perjury, that the information I provide to Workforce Solutions

Northeast Texas is true and accurate. I understand that: (1) a person who obtains or attempts to

obtain, by fraudulent means, services to which the person is not entitled may be prosecuted under

applicable state and federal laws, (2) for initial eligibility, I am entitled to be notified about my eligibility for

services within 20 calendar days from the date all of my eligibility documents are received by Workforce

Solutions Northeast Texas; (3) I, or my representative, may appeal denial, reduction, or termination of

services; (4) services will be provided without regard to sex, race, creed, color, national origin, or

disability; and (5) the information I provide or a third party provides regarding my income and

circumstance is confidential.

I GIVE PERMISSION TO THE Texas Workforce Commission (TWC), and Workforce Solutions

Northeast Texas (or the agency under contract), to contact a third party to verify income, family

size, residence, education, training, Attorney General compliance, and any other information

needed to determine eligibility and to use Social Security numbers provided by me for

identification and verification of benefits, child support payments which the family receives, and

UI income information. I give the child care staff authority to share information with other

agencies working with me such as Texas Health and Human Services Commission (HHSC) and

TWC.

I UNDERSTAND that by signing this form, I am applying for services from Workforce Solutions

Northeast Texas. All information/documents I provide to Workforce Solutions Northeast Texas to

complete my eligibility determination for child care services represents a complete and accurate

statement of my (the client’s) family’s circumstances at the time of application.

I CERTIFY that I will comply with all of the requirements, policies, and procedures of the Texas Workforce

Commission (TWC), Workforce Solutions Northeast Texas, and child care provider while my child is

enrolled in child care.

I AGREE to comply with the provisions of the Parent Responsibility Agreement (PRA) (Page 11 in Parent

Handbook). At placement and at each recertification, I will supply Workforce Solutions Northeast Texas

with the necessary documentation to show I am cooperating with the Office of the Attorney General if

child support has not been established for each child in my household. I will provide documentation of

the amount of child support payments received for each child in my household. I will sign form 2042A

(Parent Self Declaration Form of Compliance) certifying that my school age children are attending school

regularly and also certifying that I have not used, sold, or possessed marijuana or any other controlled

substance and have not abused alcohol. I understand I will not be eligible to receive assistance through

Workforce Solutions Northeast Texas if I am not in compliance.

____________________________________________________

____________________________

Parent Signature

Date

__________________________________________________

____________________________

Parent Signature

Date

_______________________

Case Number

Updated 04-13

Form CS008

An Application Packet Page 6

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