Form Dshs 07-106a - Ccsp Eligibility Waitlist Letter (Page 2 of 2) in pdf

Copayment

A copayment is your share of your child care cost and must be paid directly to your provider. Your copayment is

based on your family size and your monthly income.

Your monthly copayment will be $15.00 for the first two months that benefits are paid when you are removed from the

wait list.

When removed from the waitlist, and after paying $15 the first two months, your monthly copayment will be $

for

the remainder of your eligibility period.

Your monthly copayment will be $

when removed from the wait list.

You must report within 10 days if your family monthly income exceeds $

or resources exceed

$1,000,000.00. WAC 170-290-0031

1. Family size

2. Gross earned income (before taxes)

3. Self-employment income (after allowable deductions)

4. Unearned income equals (SSI, SSA, child support received, lump sum payments)

5. TOTAL INCOME (add lines 2 through 4 above)

6. Court ordered child support paid

7. Determine countable income (subtract line 6 from line 5)

(Countable income is used to determine eligibility and copayment)

8. Co-payment is calculated as follows:

Countable Income

Monthly Copayment

At or below 82% of Federal Poverty Level (FPL)

$15

Above 82% and up to 137.5% of FPL

$65

Over 137.5% and up to 200% of FPL view:

Hearing Rights

If you disagree with this decision, you may request a hearing by contacting this office or write to Office of Administrative

Hearings, P.O. Box 42489, Olympia, WA 98504-2489. You must request your hearing:



On or before the effective date of this action or no more than 10 days after we send you notice of this action, IF you

receive benefits now and you want them to continue, or



Within 90 days of the date you receive this letter.



At the hearing, you have the right to represent yourself, be represented by an attorney or by any other person you

choose. You may be able to get free legal advice or representation by contacting an office of legal services.

At the hearing, you have the right to represent yourself, be represented by an attorney or by any other person you choose.

You may be able to get free legal advice or representation by contacting an office of legal services.

Reporting Changes

Call 1-877-501-2233 or Fax 1-888-338-7410

Online at:

Mail: DSHS Customer Service Contact Center

P.O. Box 11699

Tacoma WA 98411

Include your Client ID on each page you submit.

CCSP ELIGIBILITY WAITLIST LETTER

DSHS 07-106A (08/2016)

Form Dshs 07-106a - Ccsp Eligibility Waitlist Letter Page 2

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