Form Cc-001 - Application For Child Care Assistance Page 7
Download a blank fillable Form Cc-001 - Application For Child Care Assistance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cc-001 - Application For Child Care Assistance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8RIGHTS AND RESPONSIBILITIES
CC-001 (7-17) – PAGE 6
YOUR RIGHTS
1. Section 601 of the U.S. Civil Rights Act of 1964 states, "no person in the United States shall, on the ground of race, color, or
national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any
program or activity receiving Federal financial assistance."
2. You have the right to apply for Child Care Services.
3. You have the right to a decision on the application within 30 days from the date your application is received.
4. You have the right to appeal for a hearing on the action or inaction on your case.
5. You have the right to any child care service provided in your area and available to persons in your same circumstances.
6. Information which you provide is confidential and shared with agency staff only as it relates to child care.
7. If you are determined ineligible or if your services are stopped and you disagree with the decision, you may appeal the decision
in writing within 10 calendar days of the date the decision letter is mailed. IF CHILD CARE SERVICES ARE BEING STOPPED
DUE TO NON-PAYMENT OF THE REQUIRED CO-PAYMENTS FROM YOU, AND YOU WISH TO APPEAL, YOU MUST
FILE AN APPEAL WITHIN 10 CALENDAR DAYS OF THE NOTICE DATE IN ORDER FOR CHILD CARE SERVICES TO
CONTINUE DURING THE APPEAL PERIOD.
YOUR RESPONSIBILITIES
1. You must sign this form below and complete an interview with a DES Child Care Specialist.
2. You must be a U.S. citizen or a legal resident of the U.S. in order to receive child care benefits.
3. Your child care services may be stopped if you fail to pay the designated co-payment to your child care provider.
4. You may only use child care for purposes authorized (i.e., employment or participation in a Jobs activity).
5. You must read all information sent to you. Contact your Child Care Specialist if you have any questions regarding information
that you receive on your case status or child care arrangements.
6. YOU MUST NOTIFY YOUR CHILD CARE SPECIALIST WITHIN FIVE (5) WORK DAYS WHEN OR IF:
a. You move.
b. You or any adult in your household experience a loss of employment.
c. Someone moves in or out of your home.
d. Your family’s gross monthly income increases above 85% of the State Median Income (SMI).
e. You change child care providers. Payment cannot be made for child care services if the provider has not been authorized
by your Child Care Specialist.
7. You are responsible for any additional charges not covered by DES (i.e., registration fees, late fees).
8. You must cooperate with the Arizona Department of Economic Security (DES) in order to initiate and maintain eligibility. IT
IS YOUR RESPONSIBILITY TO REPORT ALL CHANGES. Verification of the information may be requested. Failure to
comply with departmental requirements may result in a loss of child care services and you may be subject to a Waiting List
upon reapplication.
9. When a Waiting List is in effect you must comply with all Department requirements and maintain eligibility in order to retain
your placement on the Waiting List.
10. You must make efforts to improve your skills and move toward self-sufficiency in accordance with Arizona Revised Statutes
(A.R.S.) § 46-803 (K) (1). In order to receive more than 60 cumulative months of Block Grant Child Care per child you may be
asked to state how your family has made efforts to improve skills and move toward self-sufficiency in the past 12 months.
11. You must be truthful in your statements to DES or you may be charged with fraud. (A.R.S.) §§ 46-213 and 46-216 provide for
a fine and/or imprisonment as punishment for conviction of fraud.
12. You are responsible to repay overpayments incurred as determined by the DES.
13. If you file for an appeal, and elect to have services continued pending the outcome, you will be responsible to repay DES for
the cost of services during the appeal process if the hearing decision or Board of Appeals' decision is NOT in your favor.
AFFIDAVIT OF TRUTH: I hereby apply for Child Care Assistance and affirm that I have been informed of my rights and
responsibilities. I swear under penalty of perjury that statements on this form, information and documents provided by me,
or on my behalf to DES are true and correct to the best of my knowledge, that I have not withheld information, and have
honestly reported my U.S. citizenship or alien status. I understand that if I knowingly submit false information or conceal a
material fact on the application, I may be charged with fraud pursuant to A.R.S. § 13-2311, a class 5 felony. I authorize DES
to verify information through current or former employers, or other persons or institutions. I understand that I will be
responsible for overpayments.
SIGNATURE OF APPLICANT
PRINT NAME OF APPLICANT
DATE
SIGNATURE OF SPOUSE/OTHER PARENT
PRINT NAME OF SPOUSE/OTHER PARENT
DATE
P LEASE SUBMIT THE ORIGINAL AND KEEP THE COPY FOR YOUR RECORDS
(SEE REVERSE)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal