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INFORMATION PROVIDERS NEED TO KNOW

Child Care facility owners may authorize another individual to act for and as a representative of the owner. This is the “Authorized

Agent.” An authorized agent assumes the responsibility for compliance with program rules and requirements, penalties and repayment of

any overpayments. In the absence of an authorized agent, the owner assumes responsibility for compliance with program rules and

requirements, penalties and repayment of any overpayments.

Your Responsibilities

As a provider participating in the Child Care Assistance Program (CCAP), I agree to respect and maintain the confidentiality of

families participating in the CCAP and understand that I must not discriminate against such families on the basis of race, color,

national origin, religion, sex, age, or handicap. I further understand that:

I must have a valid authorization before I bill the State of

I must give at least 14 days written notice of my intent to

Alaska for services provided to CCAP families. Charges

terminate services to CCAP families and the appropriate

for services that are not on the authorization are between

child care assistance office, except upon mutual

the family and myself and cannot be billed to the State.

agreement between the family and myself.

The rate charged to CCAP families must be the rate I

I must maintain my status as a licensed, certified, or

have provided on the Rates and Responsibilities form and

approved provider in order to receive CCAP

may not be higher than the rate I charge non-CCAP families

payments.

for the same service.

I must retain and make available for inspection during

I must provide written notice of any rate and policy changes

normal business hours:

to CCAP families and the appropriate child care assistance

All required state and local permits and/or

office at least 30 days before the effective date. New rates

licenses for operation of a child care business;

become effective the 1

day of the month following 30 days

A copy of my child care policy information, if

notice.

applicable;

Billing report forms for July through April, must be submitted

A copy of all monthly child care billing statements

within 90 days after the last day of the month child care

and attendance records that reflect the date and

services were provided . For months May and June, the

time for all children in care for a period of three

monthly billing report must be submitted no later than July

years.

. Payment will be denied if submitted outside these

timeframes.

Penalty Warnings

Erroneously Obtained Payments

If the state or local child care assistance office determines that there is reasonable evidence you erroneously obtained payments, steps

will be taken to reduce or withhold future payments, to establish a repayment schedule, or to take other corrective action including

probation, suspension or termination from participation in the program.

An erroneously obtained payment means child care assistance payments received by a provider that he or she was not entitled to or

that were received while in noncompliance with a program requirement.

Sanctions for Non-Compliance

Your participation as a child care provider in the Child Care Assistance Program may be placed on probation, suspended, or

terminated for any of the following, but not limited to:

Failing to maintain status as an approved, licensed, or certified provider under the CCAP and to provide child care services in

accordance with that status;

Failing to maintain records required by the CCAP and refusing to allow an inspection of those records during scheduled

business hours;

Refusing to comply with a plan of correction or repayment plan, or cooperate with the development of the plan;

Failing to comply with any compliance action or corrective action plan or to cooperate with the establishment of the plan; and

Failing to cooperate with a representative of the Department of Health and Social Services for purposes of investigations to

determine compliance with CCAP requirements.

Fraud

You may be prosecuted or otherwise sanctioned if you knowingly give false, incorrect or incomplete information to obtain or try to

obtain Child Care Assistance Program payments you are not eligible for, or to help someone else obtain payments for which they are

not eligible. If you are found to have committed an intentional program violation or convicted of defrauding the Child Care Assistance

Program, you may be disqualified from program participation and obligated to repay any amounts attributable to the intentional

program violation or fraudulent act(s), in addition to any applicable criminal penalties.

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 this document.

__________________________________________ ________________________________________________________________

Printed Name of Owner

Signature of Owner

Date

___________________________________________________________________________________________________________

Printed Name of Authorized Agent, if applicable

Signature of Authorized Agent, if applicable

Date

CC 12 (06-3921) rev 08/11

Page 2 of 2

Form Cc 12 - Child Care Assistance Program - Child Care Provider Rates And Responsibilities Form Page 2

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