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CHILD CARE ASSISTANCE PROGRAM

For Office Use Only

CHILD CARE PROVIDER

RATES AND RESPONSIBILITIES

Facility Name:

Phone Number:

Owner Name:

FAX Number:

Physical Address:

Email Address:

Mailing Address:

SSN or EIN:

City, ST, Zip Code:

Authorized Agent Name:

(if different than Owner, complete the following for the agent):

Physical Address:

Mailing Address:

City, ST, Zip Code:

Phone Number:

CHECK ONLY ONE OF THE FOLLOWING PROVIDER TYPES:

Licensed



Center

Group Home

Home

Certified



Dept. of Defense

Coast Guard

Tribal

(attach supporting documents)



Approved Relative -

Relative means an individual that is related by

Approved Non-Relative

marriage, blood or court decree, to a child who is the grandchild, great-



PASS I In-Home Care

Approved

grandchild, niece, great-niece, nephew, great-nephew or sibling. If a sibling

(care provided in the

the provider and the child in care must live in a separate residence.

child’s own home



CHECK ONE:

My rates are the same as the State rate (do not complete the table below) OR

My rates are listed below

Infant

Toddler

Preschool Age

School Age

Birth through 18 months

19 months through 36 months

37 months through 6 years

7 years through 12 years

Full

Part

Full

Part

Full

Part

Time

Part Time

Time

Monthly

Daily

Hourly

Note: Full Time = Over 5 and up to 10 hours of care per day. Part Time = Up to and including 5 hours of care per day.



LICENSED/CERTIFIED ONLY: DO YOU CHARGE A REGISTRATION FEE?

Yes



Amount $___________

Per Family

Annual

Per Child

One-Time

HOURS OF OPERATION:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Hours Open

SCHEDULED CLOSURES (such as a holiday) and DATES:

Under penalty of perjury or unsworn falsification, I certify that the information I have provided on this form is truthful and accurate

and that I have read, or had read to me, and understand my responsibilities as described in the “Information Providers Need to

Know” on page two of this form.

_______________________________________________

______________________________________________________________

Printed Name of Owner

Signature of Owner

Date

Printed Name of Owner’s Authorized Agent

Signature of Owner’s Authorized Agent

Date

CC 12 (06-3921) rev 08/11

Page 1 of 2

Form Cc 12 - Child Care Assistance Program - Child Care Provider Rates And Responsibilities Form

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