Subsidized Child Care Application Form - Commonwealth Of Pennsylvania Page 11

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Rights and Responsibilities Form

For Low-Income/Former TANF/Head Start Cases

I understand that:

1. The information in this form will be kept confidential.

2. I may pick any eligible provider to care for my children. An eligible provider meets the requirements of the Subsidized Child Care Program and agrees to follow the Department

of Human Services’ rules.

3. I may need to pick another provider if my provider is not eligible to participate in the Subsidized Child Care Program.

4. I will be told in writing when a change causes my family to lose help in paying for child care and may ask for a hearing if I disagree with a decision that the CCIS agency has made.

5. I must give the CCIS agency true and complete information and proof of information as requested.

6. I must report the following to the CCIS agency within 10 days of the change:

● Loss of work including layoffs or strikes

● Telephone

● Who is providing child care for my child(ren)

● Decrease in hours of work, education or training below an average of 20 hours a week

● Address

● Number of days or hours my child needs care

● Number of people who live in the house with the child(ren)

● Marital Status

● Maternity leave status

7. I must pay back the cost of any child care I receive during a period of time when I am not eligible.

After the CCIS has determined you eligible for child care and funds are available to enroll your child(ren) in care, you need to know the following:

You must pay a co-payment to your provider every week. The co-payment is due to the provider on the first day of the week that your child(ren) attend(s). It is important that

you pay your co-payment on time. If you do not pay your co-payment on time, you may lose the CCIS agency’s help in paying for your child care.

2. Unless your child is ill, your child must attend the child care program on all the days that you told the CCIS he/she needed child care. If you need to make a change due to your

work, education or training schedule, you must call the CCIS. You could lose the CCIS agency’s help in paying for your child care costs if your child is absent for five days in a

row for a reason other than: (1) Illness, injury or hospitalization of the child or another family member; (2) Family/maternity leave; (3) Visitation with a parent who does not live

with the child(ren) or (4) A break in your work, education or training.

3. If your child is absent for more than 25 enrollment days between July 1 and June 30, you will be responsible to pay the provider the daily rate for each day of absence beginning

with the 26th absence. You must pay the provider’s daily rate in addition to your weekly co-payment. For example, if your co-payment is $20/week and the daily rate is $20,

you must pay $40 for the week that includes your child’s 26th day of absence.

4. The CCIS will pay a child care center, family child care home or a group child care home for up to 15 days when the facility is not open to care for your child. The CCIS is

unable to pay an alternate child care provider during these 15 days when your provider is not open to care for your child.

5. If the CCIS sends you a Notice of Adverse Action, it means there may be a change in your eligibility for subsidized child care. If you do not understand what is written in the

notice, you should contact the CCIS agency immediately. If you disagree with a decision that the CCIS agency has made, you may ask for a hearing to review the decision.

You must inform the CCIS that you do not agree with the decision by doing one of the following: (1) Fill out the bottom part of your notice or write a letter and then mail, fax or

take the information to the CCIS; and (2) Call the CCIS to discuss the reason you do not agree with the decision and follow-up by putting your concerns in writing within seven

days following the date of your telephone call with the CCIS. If you want the CCIS to continue to help pay for your child care during this process, you must mail, fax or take the

bottom part of your notice or the letter that you wrote to the CCIS or call the CCIS on or before the date on the Notice of Adverse Action.

6. You may choose a new provider at any time. However, you must tell the CCIS agency before your child begins child care with a different provider. The CCIS agency will authorize

the transfer and continue to help pay for your child care after the transfer if: your family co-payments are up-to-date AND you continue to be eligible for the CCIS agency’s help in

paying for your child care AND the new provider that you choose meets the requirements of the Subsidized Child Care Program. The new provider must also agree to follow the

Department of Human Services’ rules. If the CCIS does not authorize the transfer, you will be responsible for paying the total cost of child care at the new provider.

Date discussed with parent/caretaker: ________ / ________ / ________

Initials of worker: ________

CY 922 LI 12/12

CY 868 12/15