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I certify that all of the information I have provided is true and correct. I understand that state officials may verify the
information and that deliberate misrepresentation may subject me to prosecution under applicable State and Federal
criminal statutes. I further understand that upon my approval for this program, I may be assessed a fee based on the
information I have provided. I agree, by my signature, to pay that fee according to the terms and conditions of the
approved child care provider. I further certify that I have read the Applicant Rights and Responsibilities and will comply
with the Responsibilities.
Please print your name:
Signature of Parent/Caretaker: Date: / /
Name of Child Care Provider Selected:
Address of Child Care Provider Selected:
NOTE: The SC Voucher Program WILL NOT pay for any children who are served prior to receiving written authorization by the
SC Voucher Program.
n
n Have you completed all sections of the Application?
n
n Have you signed and dated this Application?
n
n Have you attached copies of paystubs for the last 30 days, or a letter from your employer on company letterhead
that shows your gross pay and hours worked for the last 30 days? This information must also be provided for your
spouse or your child’s second parent if in the home.
n
n If you attend school or a training program, have you attached a copy of the schedule and proof of paid registration
for the term during which you are applying for services? This information must also be provided for your spouse or
your child’s second parent if in the home.
n
n If you are self-employed, did you attach your most recent income tax forms?
If you are not sure what to send, or need assistance in completing this application, please call 1-800-476-0199.
Return Application and documentation to:
SCDSS, SC Voucher Program, P.O. Box 100160, Columbia, SC 29202-3160 or Fax to 1-800-310-5417
Applicant Responsibilities
1. It is your responsibility to provide current and accurate
verification of gross family income, family size, age of
child(ren), change of address, and employment/school/training
and to report all changes to this information within 10
calendar days after the change occurs.
2. It is your responsibility to pay your provider for child
care services you receive before or after the authorized
dates of service.
3. It is your responsibility to choose a child care provider
within 15 calendar days from the date you are notified
of your eligibility for services.
4. It is your responsibility to pay a weekly client fee, which
is based on your family size and income, for each child
receiving child care services through the SC Voucher
Program. The weekly fee is due to your provider before
the weekly child care service is provided. You may also
be responsible for paying the difference between the
maximum amount the SC Voucher Program pays and
what the provider charges.
5. It is your responsibility to assure your child(ren)
attends the provider in accordance with SC Voucher
Program attendance policies.
6. It is your responsibility to call the SC Voucher Program
at 1-800-476-0199 to request approval to transfer to a
new provider before you stop attending one provider
and before transferring to another.
Applicant Rights
1. You have the right to choose a child care center, family
child care home, group child care home, church facility,
or care by a neighbor, friend, or relative. If you are
receiving services under Child Protective Services or
Foster Care, you may choose only licensed facilities or
programs.
2. You have the right to visit your child any time the child
is in the provider’s care.
3. You have the right to make complaints or discuss
areas of concern or suggestions regarding the SC
Voucher Program by calling 1-800-763-2223.
4. You have the right to receive a fair hearing regarding
any decision that results in the denial or termination of
services, provided that the decision is not due to
funding. Requests for fair hearings shall be submitted in
writing to Individual and Provider Rights, SCDSS,
P.O. Box 1520, Columbia, South Carolina, 29202-1520.
6. Please read the following Applicant Rights and Responsibilities.
7. By my signature below:
CHECKLIST
