Application For Child Care Assistance (Page 3 of 4) in pdf

RIGHTS AND RESPONSIBILITIES:

The fact that you are applying for or receiving assistance from this agency means you have certain rights and responsibilities.

You have the right to confidentiality -- that means that the information given by you will not be released without your written consent, except

to agencies and officials as allowed by law. We do not discriminate in the delivery of services. This means you will not be treated

differently from others because of your race, color, sex, age, disability, religious beliefs, nation origin or political beliefs. If you think you

have been discriminated against, you can file a complaint which will be investigated and appropriate action will be taken.

A decision will be made on your application within 30 days after the date the application is received. You will receive written notice of the

decision. You can request a Fair Hearing to have the Department of Social Services review the decision of the OFS Parish office handling

your case if you think it is not fair. You or your representative may request a Fair Hearing, orally or in writing, if you disagree with any

action taken on your case. Your case may be presented at the hearing by any person you choose.

AGREEMENT: I agree to let the office know within ten days if any of the following changes occur. I understand that I must report changes

that occur after I send in my application, as well as changes that occur after I am determined eligible.

•

Change in Address

•

Change in Members of my Household, including anyone who moves in or out

•

Change in employment, including an interruption for at least three weeks, a change of employer, or a change in the number of hours

worked

•

Change in income if household’s gross monthly income changes more than $100 in earned income or $50 in unearned income

•

Change in job training or educational program, including an interruption for at least three weeks, a change of programs, or a change

in the number of hours of attendance

•

Change in Child Care Providers or Provider’s Type

•

Change in location of where care is being provided

•

Change in Days or Hours Child(ren) are in the child care provider’s care

•

Child’s absence from Child Care for five or more consecutive days or when child(ren) are no longer in the child care provider’s care

•

Beginning or ending of disability

•

Termination of job search

If I am in a Food Stamp Semi-Annual Reporting (SAR) household, I understand I am only responsible for reporting within ten days the

following:

•

Change in gross monthly income, which results in the household's income exceeding the gross income limit for food stamps.

•

Change of Child Care providers.

•

A child receiving child care benefits moves out of the home or is no longer in the child care provider’s care.

•

Interruption of at least three weeks, or termination of employment, training, or education for any parent or adult household member.

•

Termination of job search.

If a child is absent from Child Care for five or more consecutive days, the child may no longer be eligible for Child Care Assistance benefits.

If you have not reported an excusable reason for the absence, your child’s eligibility will terminate after ten consecutive days of absences.

Providing false information, withholding information, or failing to report any of the changes as described above is subject to penalty under

the law. If providing false information or withholding information causes an overpayment for child care, you may be required to repay the

amount of ineligible benefits that you received to the Office of Family Support. If you purposely fail to report any information that causes

you to receive benefits for which you are not eligible to receive, fraud charges may be brought against you and you may be disqualified

from participating in the program

Social Security Numbers are not required for Child Care Assistance eligibility and eligibility cannot be denied for failure to provide Social

Security Numbers.

I give permission to the Agency to contact whomever necessary to verify my need for assistance. In addition, I hereby waive the

confidentiality of my name and Social Security Number, if provided, so that information may be furnished to employers, government

agencies, and any other parties deemed necessary in order to verify my income and need for assistance, or for data collection or statistical

purposes.

With my signature below, I certify that I have read and understand my rights and responsibilities. I hereby declare that the times care is

needed as listed in item 3 are the times when I and any other Training or Employment Mandatory Participant are working and/or attending a

job training or educational program or traveling to and from these activities. I certify under penalty for perjury that all information given on

this application form is true and correct to the best of my knowledge.

Signature of Applicant

Date

Signature of Legal or Non-Legal Spouse

Date

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Application For Child Care Assistance Page 3

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