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


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
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
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
. Payment will be denied if submitted outside these
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.
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
Printed Name of Authorized Agent, if applicable
Signature of Authorized Agent, if applicable
CC 12 (06-3921) rev 08/11
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