Fillable Caretaker Application for Child-Only Reach Up (Vermont)

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Caretaker Application for Child-Only Reach Up (Vermont)

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Caretaker Application for Child-Only Reach Up
Applying for assistance
■ You may use this application to apply for Child-Only Reach Up — monthly cash assistance that
helps eligible adults care for the minor, dependent children of their relatives or family friends.
■ If you want to apply for 3SquaresVT, Essential Person, Fuel Assistance or Reach Up for yourself,
you must use our regular 202 application. Call 1-800-479-6151 or go to mybenets.vt.gov.
Eligibility for benefits
To be eligible for Child-Only Reach Up, the child must:
■ Be under 18 (with a few exceptions
*
)
■ NOT be getting SSI benets (if an eligible child lives with a sibling who gets SSI, you must let us know
in #3 on page 3)
■ NOT be in foster care
■ Have little or no income of their own
■ Be living with/cared for by someone other than a legal, step or adoptive parent
* A full-time HS student expected to graduate before their 19th birthday is eligible through the month of graduation.
* A full-time HS student who is disabled is eligible through the month of graduation or 19th birthday, whichever is rst.
(Arabic) .3092-247-855-
1
ﻢﻗﺮﺑ ﻞﺼﺗا .نﺎﺠﻤﻟﺎﺑ ﻚﻟ ﺮﻓاﻮﺘﺗ ﺔﯾﻮﻐﻠﻟا ةﺪﻋﺎﺴﻤﻟا تﺎﻣﺪﺧ نﺈﻓ ،ﺔﻐﻠﻟا ﺮﻛذا ثﺪﺤﺘﺗ ﺖﻨﻛ اذإ :ﺔظﻮﺤﻠﻣ
ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-247-3092. (French)
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-247-3092. (Spanish)
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-247-3092.
(Vietnamese)
 :    
             1-855-247-3092 (Nepali)
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-247-3092. (German)
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-855-247-3092. (Cushite)
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-247-3092. (Russian)
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-855-247-3092. (Portuguese)
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-247-3092 まで、お電話にてご連絡ください。(Japanese)
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-247-3092。(Chinese)
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-247-3092. (Italian)
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. –Nazovite 1-855-247-3092. (Serbo-Croatian/Bosnian)
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-247-3092. (Tagalog)
เรียน: ถ้ าคุณพูดภาษาไทยคุณสามารถใช้ บริการช่ วยเหลือทางภาษาได้ ฟรี โทร 1-855-247-3092. (Thai)
Page 2
FACTS YOU NEED TO KNOW
CHILD SUPPORT
If you get Child-Only Reach Up, you'll have to:
■ Apply for services from, and cooperate fully
with, the Ofce of Child Support (OCS).
■ Pursue child support for any child entitled
to get it, whether or not they're getting a
Child-Only Reach Up grant.
You DON'T need to complete a separate application
for child support services. Just complete this form.
If you feel pursuing child support could put
your safety or a child’s safety at risk, see #8 on
page 9 for more information.
DISCRIMINATION COMPLAINTS
DCF is an equal opportunity provider. We
don't exclude people from programs or deny
them benets because of race, color, age,
sex, religion, national origin, marital status,
disability, sexual orientation, gender identity,
or political beliefs. Federal law prohibits
discrimination on the basis of race, color,
age, sex, religion, national origin, disability
or political beliefs.To le a discrimination
complaint with:
1. DCF's Consumer Concerns Team:
□ (802) 241-0925
□ AHS.DCFConsumerConcerns@vermont.gov
□ DCF Commissioner's Ofce, Consumer
Concerns Team, 280 State Drive, HC 1
North, Waterbury, VT 05671-1080
2. Dept of Health and Human Services (HHS):
□ https://ocrportal.hhs.gov/ocr/
smartscreen/main.jsf
□ HHS Director, Ofce for Civil Rights,
Room 515-F, 200 Independence Avenue
S.W., Washington, D.C. 20201
□ OCRComplaint@hhs.gov
□ VOICE: (202) 619-0403
□ TTY: 1-800-537-7697
THE APPLICATION PROCESS
1. Complete this application. Answer the
questions completely and honestly.
If you complete this form by hand, PRINT
clearly using a pen.
To do it electronically:
a. Go to http://dcf.vermont.gov/benets/
reachup/child-only.
b. Download the form to your computer.
c. COMPLETE it, SAVE it and then PRINT a
copy to submit.
2. Check your application.
■ Make sure you’ve signed in all the
required sections:
□ #11: Signature & authorization for
child support services on page 11
□ #12: Authorization for electronic child
support payments on page 12
■ Make sure you've read and understand
the information on pages 13 to 16.
3. Submit your completed application.
DCF - Economic Services Division
Application & Document Processing Center
280 State Drive
Waterbury, VT 05671-1500
You can also drop it off at a district ofce.
To nd your ofce, call 1-800-479-6151
or go to http://dcf.vermont.gov/esd/
contact-us/districts.
4. Call one of the numbers below if you
have questions or need help applying.
GENERAL: Call ESD at 1-800-479-6151.
SENIORS: If you're age 60 or older,
call Vermont’s Senior Helpline at
1-800-642-5119.
TTY/RELAY SERVICE: If you're deaf or hard
of hearing, dial 7-1-1.
Page 3
First name, middle name, last name and sufx (Jr., Sr., III, etc.) Date of birth (mm/dd/yyyy)
Social Security number
Phone number where you can be reached
(
) –
Email address
Mailing address, line 1 Apartment/suite number
Mailing address, line 2
City/Town State Zip code
Physical or home address  Check if same as mailing address
Apartment/suite number
City/Town State Zip code
1. Tell us about you, the caretaker applying
Application for Reach Up Caretaker Benets
If you complete this application by hand, print clearly using a pen.
2. Tell us how you'd like to get child-only grant payments (if approved)
  On an EBT card that you can use to buy goods or get cash anywhere it's accepted
 By direct deposit into one bank account
If you chose direct deposit, provide the information below.
Bank Name ABA Routing/Transit # Account # Account Type
 checking
 savings
3. Tell us about any siblings in the household who get SSI
If an eligible child lives with a sibling who gets SSI, list the sibling below.
Sibling's Full Name (rst, middle, last name & sufx (Jr., Sr., III, etc.) Date of Birth
4. Tell us if you have safety concerns related to pursuing child support
If you get Child-Only Reach Up, you will have to pursue child support for any child who is entitled to get it —
whether or not they are getting a Reach-Up grant.
Do you feel pursuing child support could put your safety or a child's safety at risk?
 NO      - If NO, skip to #5.  YES - If YES, check one of the boxes below.
I would like to:
Request a waiver from participating in the child support process. See #8 on page 9 for more info.
   Pursue child support anyway. I can request a waiver later on if the situation changes.
202CARE
Revised 01/2020
Page 4
5. Tell us about each child you are applying for
You may use this form to apply for more than one child if they are siblings. If they are cousins or not related,
you must complete separate applications. Answer as best you can. Use extra paper if needed.
INFORMATION ON CHILD #1
First, middle, last name & sufx (Jr., Sr., III, etc.)
CITIZENSHIP KINSHIP ARRANGEMENT
U.S. citizen
Refugee
Asylee
Legal alien
Other
Informal
Minor guardianship
Conditional custody
Permanent guardianship
DOB (mm/dd/yyyy) Place of birth
Male
Female
Social Security number Relationship to you
Were the parents married when the child
was born?
Yes No  Not sure
If they weren't married, was paternity established?
 Yes - voluntarily* Yes - by court order  No  Not sure
Is there a child support order in place for this
child? Yes No  Not sure
Date of order Weekly support
$
Past support owed?
Yes No  Not sure
Is the child covered under a parent's health
insurance?
Yes No  Not sure
Type of coverage
Name of insurance company
Parent 1 Parent 2
Name (last, rst, middle initial) Name (last, rst, middle initial)
Any other names (maiden name, nickname, alias) Any other names (maiden name, nickname, alias)
Gender:
Male Female
Social Security number Gender:
Male Female
Social Security number
Date of birth Place of birth Date of birth Place of birth
Parent incarcerated?
Yes No
Parent deceased?
Yes No
Parent incarcerated?
Yes No
Parent deceased?
Yes No
Phone number (with area code) Phone number (with area code)
Email address Email address
Mailing address:
Current Last known Mailing address: Current Last known
Physical address if different: Current Last known Physical address if different: Current Last known
Employer's name & address: Current Last known Employer's name & address: Current Last known
* The parents signed a Voluntary Acknowledgment of Parentage (VAP) to establish parentage because they were not married at
the time of the child’s birth. This is usually done at the hospital shortly after a child is born.
MEMB
ABSP
ABSP
Page 5
5. Tell us about each child you are applying for (continued...)
MEMB
INFORMATION ON CHILD #2
First, middle, last name & sufx (Jr., Sr., III, etc.)
CITIZENSHIP KINSHIP ARRANGEMENT
U.S. citizen
Refugee
Asylee
Legal alien
Other
Informal
Minor guardianship
Legal custody
Permanent guardianship
DOB (mm/dd/yyyy) Place of birth
Male
Female
Social Security number Relationship to you
Were the parents married when the child
was born?
Yes No  Not sure
If they weren't married, was paternity established?
 Yes - voluntarily* Yes - by court order  No  Not sure
Is there a child support order in place for this
child?
Yes No  Not sure
Date of order Weekly support
$
Past support owed?
Yes No  Not sure
Is the child covered under a parent's health
insurance?
Yes No  Not sure
Type of coverage
Name of insurance company
Parent 1 Parent 2
Is this parent the same as for child 1? Yes No
If yes, skip to the next page.
Is this parent the same as for child 1?
Yes No
If yes, skip to the next page.
Name (last, rst, middle initial) Name (last, rst, middle initial)
Any other names (maiden name, nickname, alias) Any other names (maiden name, nickname, alias)
Gender:
Male Female
Social Security number Gender:
Male Female
Social Security number
Date of birth Place of birth Date of birth Place of birth
Parent incarcerated?
Yes No
Parent deceased?
Yes No
Parent incarcerated?
Yes No
Parent deceased?
Yes No
Phone number (with area code) Phone number (with area code)
Email address Email address
Mailing address:
Current Last known Mailing address: Current Last known
Physical address if different: Current Last known Physical address if different: Current Last known
Employer's name & address: Current Last known Employer's name & address: Current Last known
* The parents signed a Voluntary Acknowledgment of Parentage (VAP) to establish parentage because they were not married at
the time of the child’s birth. This is usually done at the hospital shortly after a child is born.
ABSP ABSP
Page 6
5. Tell us about each child you're applying for (continued...)
MEMB
INFORMATION ON CHILD #3
First, middle, last name & sufx (Jr., Sr., III, etc.)
CITIZENSHIP KINSHIP ARRANGEMENT
U.S. citizen
Refugee
Asylee
Legal alien
Other
Informal
Minor guardianship
Legal custody
Permanent guardianship
DOB (mm/dd/yyyy) Place of birth
Male
Female
Social Security number Relationship to you
Were the parents married when the child
was born?
Yes No  Not sure
If they weren't married, was paternity established?
 Yes - voluntarily* Yes - by court order  No  Not sure
Is there a child support order in place for this
child?
Yes No  Not sure
Date of order Weekly support
$
Past support owed?
Yes No  Not sure
Is the child covered under a parent's health
insurance?
Yes No  Not sure
Type of coverage
Name of insurance company
Parent 1 Parent 2
Is this parent the same as for child 1? Yes No
If yes, skip to the next page.
Is this parent the same as for child 1?
Yes No
If yes, skip to the next page.
Name (last, rst, middle initial) Name (last, rst, middle initial)
Any other names (maiden name, nickname, alias) Any other names (maiden name, nickname, alias)
Gender:
Male Female
Social Security number Gender:
Male Female
Social Security number
Date of birth Place of birth Date of birth Place of birth
Parent incarcerated?
Yes No
Parent deceased?
Yes No
Parent incarcerated?
Yes No
Parent deceased?
Yes No
Phone number (with area code) Phone number (with area code)
Email address Email address
Mailing address:
Current Last known Mailing address: Current Last known
Physical address if different: Current Last known Physical address if different: Current Last known
Employer's name & address: Current Last known Employer's name & address: Current Last known
* The parents signed a Voluntary Acknowledgment of Parentage (VAP) to establish parentage because they were not married at
the time of the child’s birth. This is usually done at the hospital shortly after a child is born.
ABSP ABSP
Page 7
5. Tell us about each child you're applying for (continued...)
MEMB
INFORMATION ON CHILD #4
First, middle, last name & sufx (Jr., Sr., III, etc.)
CITIZENSHIP KINSHIP ARRANGEMENT
U.S. citizen
Refugee
Asylee
Legal alien
Other
Informal
Minor guardianship
Legal custody
Permanent guardianship
DOB (mm/dd/yyyy) Place of birth
Male
Female
Social Security number Relationship to you
Were the parents married when the child
was born?
Yes No  Not sure
If they weren't married, was paternity established?
 Yes - voluntarily* Yes - by court order  No  Not sure
Is there a child support order in place for this
child?
Yes No  Not sure
Date of order Weekly support
$
Past support owed?
Yes No  Not sure
Is the child covered under a parent's health
insurance?
Yes No  Not sure
Type of coverage
Name of insurance company
Parent 1 Parent 2
Is this parent the same as for child 1? Yes No
If yes, skip to the next page.
Is this parent the same as for child 1?
Yes No
If yes, skip to the next page.
Name (last, rst, middle initial) Name (last, rst, middle initial)
Any other names (maiden name, nickname, alias) Any other names (maiden name, nickname, alias)
Gender:
Male Female
Social Security number Gender:
Male Female
Social Security number
Date of birth Place of birth Date of birth Place of birth
Parent incarcerated?
Yes No
Parent deceased?
Yes No
Parent incarcerated?
Yes No
Parent deceased?
Yes No
Phone number (with area code) Phone number (with area code)
Email address Email address
Mailing address:
Current Last known Mailing address: Current Last known
Physical address if different: Current Last known Physical address if different: Current Last known
Employer's name & address: Current Last known Employer's name & address: Current Last known
* The parents signed a Voluntary Acknowledgment of Parentage (VAP) to establish parentage because they were not married at
the time of the child’s birth. This is usually done at the hospital shortly after a child is born.
ABSP
ABSP
Page 8
First name, middle initial Name of facility Type of facility Date of admission
6. Answer the following questions about the eligible children:
A. Does any child live in a facility other than a school or college?
Examples: hospital, nursing home, correctional facility, treatment facility, group home, etc.
YES. Provide info below
NO. Skip to next question
B.
Is any child in high school, college, vocational school or training?
YES. Provide info below
NO. Skip to next question
First name,
middle initial
Name of school School type
Expected
completion date
Enrollment status
Live on
campus?
Full-time
Part-time
Less than half-time
Yes
No
Full-time
Part-time
Less than half-time
Yes
No
Does any child listed above have an individualized Education Program (IEP) or disability that
prevents graduation before age 19?  YES  NO
First name, middle initial Time spent living in other household When not living with you, who do they live with?
days per
Week
Month
Year
First, middle, last name & sufx (Jr., Sr., III, etc.)
days per
Week
Month
Year
First, middle, last name & sufx (Jr., Sr., III, etc.)
C. Does any child live with another person some of the time?
YES. Provide info below
NO. Skip to next question
INST
SCHL
D. Is any child known by another name?
YES. Provide info below
NO. Skip to next question
CURRENT NAME: First, middle, last name & sufx OTHER NAME: First, middle, last name & sufx
ALIA
Page 9
E. Does any child have income from work study, student grant or loan?
YES. Provide info below
NO. Skip to next question
First name, middle initial Grant or loan amount Tuition and fees
Period covered
(mm/yyyy - mm/yyyy)
$ $
$ $
F. Does any child receive income from any other source (see below)?
YES. Provide info below
NO. Skip to next question
Check the types of income received and then provide details below. List gross income
(income before deductions such as taxes, insurance, child support or union dues).
Alimony
Child support
Dividends or interest
Insurance settlements
Money from others
Pensions or retirement
Promissory/mortgage note
Social Security
SSI/AABD
Trusts or annuities
Unemployment
Veteran’s benets
Worker’s compensation
Other (describe below)
First name, middle initial Type of income Gross income before deductions Due to disability?
$ per Yes No
$ per Yes No
$ per Yes No
$ per Yes No
7. Are you seeking help to cover shelter expenses for any child?
YES. Provide info below
NO. Skip to next question
STIN
UNEA
RENT
How much? (up to $540 per grant amount in Chittenden county & up to $490 in other parts of the state)
$
8. Waiver from participating in the child support process
You may request a Waiver of Cooperation if you believe a parent might physically or emotionally harm
you or the children because of something OCS might do to pursue support (e.g., contact the parent to
establish parentage) or require you to do (e.g., appear in court with the parent).
To request a waiver, check the relevant boxes in #4 at the bottom of page 3.
OCS will not actively pursue support while your request is being reviewed. If you are granted a waiver,
you may receive Child-Only Reach Up without cooperating with OCS; however, you must still provide all
the information requested about the parent. You may also request a waiver later on. If you do so, the
department will give you the form, review your request and send you a written notice of the decision.
Before beginning any legal action to pursue support, OCS will send you a notice to remind you of your
right to request a waiver. There are a few exceptions, however, including when either parent les a
court action and OCS represents the State of Vermont.
Page 10
ASSIGNMENT OF RIGHTS TO CHILD SUPPORT
To be eligible for Child-Only Reach Up, you must:
1. Agree to accept services from, and cooperate fully with, the Ofce of Child Support (OCS).
2. Assign your rights to child support for all children getting a Child-Only Grant to the State of
Vermont for the entire period they get it.
The grant may be paid with either state or federal funds. The type of funding you get will affect
your right to any unpaid child support (called arrears). Once your grant closes:
ÖState-funded grant: Any arrears that accrued while you were getting assistance will be owed
to you. If your grant reopens, the State may be entitled to some of those arrears.
ÖFederally-funded grant: Any arrears that accrued while you were getting assistance will be
owed to the State, no matter when OCS collects it.
COLLECTION AND DISTRIBUTION OF CHILD SUPPORT
While you’re getting Child-Only Reach Up:
Ö OCS will send all child support collected to DCF’s Economic Services Division (ESD).
Ö If OCS collects more current support than your grant, you’ll get the difference. However, if this
happens for two months in a row:
• The grant will be closed.
• OCS will start sending current support to you, within two business of receiving it.
• OCS will continue providing other child support services.
• OCS will send you an annual statement showing the amount of support collected.
Ö ESD will add up to $50 of current support collected to your grant as a family bonus. For
example: if $25 in current support is paid, you’ll get a $25 bonus. If $125 is paid, you’ll get a
$50 bonus. You’ll start getting bonuses two months after we start collecting child support.
ASSIGNMENT OF MEDICAL SUPPORT RIGHTS
As a condition of eligibility for health care assistance, you must assign all rights to medical
support and third party payments (e.g., insurance & court-ordered cash medical payments) to
the State of Vermont for Vermont health care services reimbursed by Medicaid. After your grant
closes, this assignment will continue as long as the children are getting health care benets.
RIGHT TO APPEAL
If you disagree with an OCS action or decision in your child support case, you may ask for a
review by a unit supervisor. If you disagree with the supervisor’s decision, ask for a Request for
Administrative Review form. When OCS receives your completed form, someone will contact you
to complete the review process. If you get state-funded assistance and disagree with a decision
about child support forwarded from OCS to ESD, you may ask for a fair hearing.
9. Important information
Page 11
BY SIGNING BELOW, I CERTIFY AND AGREE:
■ To assign any rights I have to child and medical support for the eligible children in this
application to the State of Vermont — for the duration of the Child-Only Reach Up grant.
■ To accept services from, and cooperate fully with, OCS unless I request and am granted a
Waiver of Cooperation, which I may do at anytime.
■ That I have read and understand the information on page 10 and above.
■ That I have read, understand & accept the ESD Rights and Responsibilities as outlined on
page 15 and OCS Statements of Understanding as outlined on page 16.
■ That the information provided is true and complete to the best of my knowledge.
■ To report changes that may affect my benets by calling 1-800-479-6151 — within 10
days from when they happened (e.g., changes to kinship care arrangement, income or
living arrangement).
YOU MUST SIGN & DATE YOUR APPLICATION HERE
UNSIGNED APPLICATIONS WILL BE RETURNED
I certify that the information provided on this application is true and complete to the
best of my knowledge.
Signature of Caretaker Applicant Date
Sign here
Sign here
11. Signature & authorization for child support services
10. Are you interested in these additional services?
Yes
No
WIC PROGRAM:
If you're caring for a child under ve, you may qualify for additional help with food, health
screenings and nutrition education. If so, would you like someone from WIC to contact you?
You can also call 1-800-464-4343 toll free to learn more.
Yes
No
VOTER REGISTRATION:
If you are not registered to vote where you live now, would you like a voter registration
application? If you do not check either box, you will be considered to have decided not
to register to vote at this time.
Applying to register or declining to register to vote will not
affect your eligibility for benets or amount granted to you by ESD. If you would like help in
lling out the voter registration application form, we will help you. The decision whether to
seek or accept help is yours. You may ll out the application form in private. If you believe
that someone has interfered with your right to register or to decline to register to vote, your
right to privacy in deciding whether to register or in applying to register to vote, or your right
to choose your own political party or other political preference, you may le a complaint
with the Secretary of State’s Ofce at 128 State Street, Montpelier, VT 05633-1101, or call
1-802-828-2363, or 1-800-439-8683 (toll free).
Page 12
You must choose one of the payment options below:
Once we get your authorization, it'll take about 30 days for payments to begin. Call 1-800-786-3214
to nd out when OCS received your payment or change your electronic payment option.
1. Direct deposit to one bank account:
Depending on the bank, funds are usually available 7-10 business days after OCS receives a
payment. Contact your bank to nd out if a payment has been credited to your account.
2. U.S. Bank ReliaCard®:
ReliaCard is a Visa® Prepaid Debit Card that can be used to make purchases, pay bills and
get cash everywhere Visa debit cards are accepted
1
. It is not a credit card. You don’t need a
bank account.
Your ReliaCard will be mailed to the address you provide within 7 - 10 business days from the
date of enrollment. Sign up to get email or text
2
alerts when funds are added to your card.
1
Fees and transaction limits apply. See fee schedule on page 14 for details.
2
Standard text messaging charges apply through your mobile carrier; message frequency depends on account settings.
Provide your information below
Last name First name & middle initial Email address
Social Security number Preferred phone (with area code) Secondary phone (with area code)
Check one of the two options below. If you don’t make a selection, you’ll be issued a ReliaCard.
Direct
Deposit
Bank Name ABA Routing/Transit # Account # Account Type
Checking
Savings
U.S Bank
ReliaCard*
Please read the information provided on pages 13 and 14 about the ReliaCard option before
you decide which option you’d like to choose.
*If you select the ReliaCard: to help the government ght the funding of terrorism and money laundering activities, Federal
law requires all nancial institutions to obtain, verify, and record information that identies each person who opens an
account. This means that when you open an account, we will ask for your name, address, date of birth, and other information
that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents. The ReliaCard is
issued by U.S. Bank National Association pursuant to a license from Visa U.S.A. Inc. Member FDIC.
SIGN BELOW.
Unsigned applications will be returned.
This request cancels any other direct deposits I have in place with OCS.
Signature
Date
12. Authorization for electronic child support payments — after Reach Up ends
Sign here
Page 13
Disclosure Information about the U.S. Bank ReliaCard®
U.S. Bank ReliaCard
®
Pre-Acquisition Disclosure
Program Name: Vermont Child Support
Reference Date: June 2017
You have options as to how you receive your payments,
including direct deposit to your bank account or this prepaid card.
Ask your agency for available options and select your option.
Monthly fee
$0
Per purchase
$0
ATM withdrawal
$0 in-network
$1.25* out-of-network
Cash reload
N/A
$0ATM Balance Inquiry (in-network or out-of-network)
Customer Service (automated or live agent)
Inactivity (after 365 days with no transactions)
$0 per call
$2.00 per month
We charge 3 other types of fees. One of them is:
Card Replacement (standard or expedited delivery) $0 or $15.00
* This fee can be lower depending on how and where this card is used.
See the accompanying Fee Schedule for free ways to access your funds and balance information.
No overdraft/credit feature.
Your funds are eligible for FDIC insurance.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services inside the card package or call
1-855-203-3824 or visit usbankreliacard.com.
Page 14
Your funds are eligible for FDIC insurance. Your funds will be held at U.S. Bank National Association, an FDIC-insured institution, and are insured up to
$250,000 by the FDIC in the event U.S. Bank fails. See fdic.gov/deposit/deposits/prepaid.html for details.
No overdraft/credit feature.
Contact Cardholder Services by calling 1-855-203-3824, by mail at P.O. Box 551617, Jacksonville, FL 32255 or visit usbankreliacard.com.
For general information about prepaid accounts, visit cfpb.gov/prepaid. If you have a complaint about a prepaid account, call the Consumer Financial
Protection Bureau at 1-855-411-2372 or visit cfpb.gov/complaint.
The ReliaCard is issued by U.S. Bank National Association pursuant to a license from Visa U.S.A. Inc. ©2018 U.S. Bank. Member FDIC.
CR-16926173
U.S. Bank ReliaCard
®
Fee Schedule
Program Name: Vermont Child Support
Effective Date: May 2018
All fees Amount Details
Get cash
ATM Withdrawal (in-network) $0
This is our fee per withdrawal. “In-network” refers to the U.S. Bank or MoneyPass
®
or SUM
®
ATM networks. Locations can be found at usbank.com/locations or moneypass.com/atm-
locator or sum-atm.com.
ATM Withdrawal
(out-of-network)
$1.25 This is our fee per withdrawal. This fee is waived for your first ATM withdrawal per month,
which includes both ATM Withdrawals (out-of-network) and International ATM Withdrawals.
“Out-of-network” refers to all the ATMs outside of the U.S. Bank or MoneyPass or SUM ATM
networks. You may also be charged a fee by the ATM operator even if you do not complete a
transaction.
Teller Cash Withdrawal $0 This is our fee for when you withdraw cash off your card from a teller at a bank or credit union
that accepts Visa
®
.
Information
ATM Balance Inquiry (in-network) $0
This is our fee per inquiry. “In-network” refers to the U.S. Bank or MoneyPass or SUM ATM
networks. Locations can be found at usbank.com/locations or moneypass.com/atm-locator or
sum-atm.com.
ATM Balance Inquiry
(out-of-network)
$0 This is our fee per inquiry. “Out-of-network” refers to all the ATMs outside of the U.S. Bank or
MoneyPass or SUM ATM networks. You may also be charged a fee by the ATM operator.
Using your card outside the U.S.
International Transaction 3%
This is our fee which applies when you use your card for purchases at foreign merchants and
for cash withdrawals from foreign ATMs and is a percentage of the transaction dollar amount,
after any currency conversion. Some merchant and ATM transactions, even if you and/or the
merchant or ATM are located in the United States, are considered foreign transactions under
the applicable network rules, and we do not control how these merchants, ATMs and
transactions are classified for this purpose.
International ATM Withdrawal $1.25 This is our fee per withdrawal. This fee is waived for your first ATM withdrawal per
month, which includes both ATM Withdrawals (out-of-network) and International
ATM Withdrawals. You may also be charged a fee by the ATM operator even if you
do not complete a transaction.
Other
Card Replacement $0 This is our fee per card replacement mailed to you with standard delivery (up to 10 business
days).
Card Replacement Expedited Delivery $15.00 This is our fee for expedited delivery (up to 3 business days) charged in addition to any Card
Replacement fee.
Inactivity
$2.00
This is our fee charged each month after you have not completed a transaction using your
card for 365 consecutive days.
Page 15
ESD RIGHTS AND RESPONSIBILITIES
If you need help understanding these rights and responsibilities, call 1-800-479-6151.
a. You may request a fair hearing if you disagree with a decision about benets. To do so:
■ Call the ESD Benets Service Center at 1-800-479-6151.
■ Write the ESD Deputy Commissioner, Department for Children and Families, HC 1 South,
280 State Drive, Waterbury, VT 05671-1020.
■ Write the Human Services Board, 14-16 Baldwin St, 2nd Floor, Montpelier, VT 05633-4302.
b. You have the right to get a copy of this application. Call 1-800-479-6151.
c. You have the right to a timely decision. Unless a delay is caused by you, an unexpected emergency
or administrative problem beyond ESD’s control, expect a decision within 30 days of applying.
d. If you have a disability, you may be entitled to free aids & services (called reasonable
accommodations) to help you participate. Call 1-800-479-6151 to let us know. This could include:
■ Giving you program information in accessible formats (e.g., large print, audio or Braille)
■ Giving you more time to gather the documents you need to give us
e. You have the right to privacy. We are committed to protecting your privacy and keeping
information about your case condential—in compliance with the law. We will only share
information when it's connected to program administration, allowed by law/court order or you give
your permission. This is also required of all agencies that work with us.
f. If your household includes people who are not eligible because of their immigration status,
you can still apply for those who are eligible. We'll verify the immigration status of all non-
citizens who apply with the U.S. Citizenship and Immigration Services. Getting benets from ESD
can affect an immigrant’s sponsor or immigration status. You may contact Vermont Legal Aid if you
have legal questions before applying: 1-800-889-2047.
g. You are responsible for reporting changes. You must report changes within 10 days from
when they happen by calling 1-800-479-6151. This includes any change to your kinship care
arrangement. You must also tell ESD immediately if a child gets benets from another state.
h. You must provide a Social Security number (SSN) for each person on this application. Federal
and State law requires it as a condition of eligibility. We use SSNs to pursue child support, prevent
individuals from getting duplicate benets, and verify the accuracy of the information provided.
i. You are responsible for the accuracy of the information provided on this application. The
information provided is subject to verication by federal, state and local ofcials. If the information
you provide is not accurate, your benets may be reduced, you may be asked to repay benets, you
may be denied benets or you may be subject to an administrative disqualication hearing and/or
criminal prosecution.
j. You must cooperate with ESD if your application is selected for a quality control review. This
includes providing proof of any required information and authorizing us to get that proof if you are
not able to provide it.
k. You must not lie or hide information to get benets your household should not get. It is fraud
if you or any adult in your household knowingly provides false or misleading information to get,
attempt to get, or help someone else get Child-Only Reach Up benets.
Page 16
OCS STATEMENTS OF UNDERSTANDING
If you need help understanding these statements, call 1-800-786-3214.
a. I can get a copy of this application. Call 1-800-786-3214.
b. OCS representatives act on behalf of the State of Vermont to enforce child support laws; they
do not act in the interests of any particular person or party; and OCS lacks the authority to
become involved in custody and visitation issues.
OCS does not act as my personal advocate
or representative in any legal proceedings before the Family Division of Superior Court; must make
many discretionary decisions concerning best implementation of its policy objectives; and is guided
not only by the economic interests of an individual case, but also by the best interests of a child.
When OCS becomes involved in my case, it will investigate and make recommendations to the court
based upon its interpretation of the law and facts.
c. I understand the role of OCS and my right to get my own attorney in connection with this
matter.
In addition to OCS participation in my case, I may present my own information, testimony
and witnesses in any legal proceedings before the Family Division of Superior Court.
d. By receiving OCS services, I’ll receive all services they deem appropriate, many which are
automatic.
Services include locating a parent for the purpose of collecting child support, establishing
parentage, establishing a child/medical support order, reviewing the amount of child support paid to
ensure it is consistent with guidelines, modifying a child support order due to a change in income or
circumstances of one or both of the parents, collecting and distributing child support payments, and
enforcing a child support order. Other services that may be appropriate include certication of arrears
with state and federal tax departments, reports to credit bureaus, lottery offsets, administrative wage
withholding, data matches with nancial institutions, trustee process, liens and other legal remedies.
Parties may not receive prior notication of every process OCS undertakes. It is my responsibility to
notify OCS in writing when I no longer want services from OCS.
e. Child support payments must be made through OCS. Payments made directly from one parent
to the other parent must be turned over to OCS for issuance. I understand that failure to do so may
result in the termination of OCS services.
f. If money is sent to me in error or issued to me based on insufcient funds, I must return the
money.
If I don’t return the money, I authorize OCS to deduct such payments from my account or
from future payments until this obligation is satised.
g. OCS is required to submit minimal information about me to a national directory used only
by other state child support agencies.
Federal law prohibits the release of information about
those who are at risk of harm from family violence. If I believe that my children or I am at risk, I
understand that I may request in writing that OCS not release my information to the directory. I
further understand that if I ask OCS not to release my information, there may be delays in my case
because some automatic processes may not go forward as usual.
h. After I try to resolve an issue with an OCS caseworker and supervisor, I have the right to
request an OCS administrative review of any decision or action taken by OCS in my child
support case.
I may call my OCS caseworker to request an Administrative Review Form or write
to OCS, ATTN: Intercept Unit, 280 State Drive, Waterbury, VT 05671-1060. I must explain my
complaint, request an administrative review, and provide the following information: my name, Social
Security number, address, daytime phone number, and whether I want the review conducted in
person, over the phone, or by mail.
i. If a court order requires either parent to provide health insurance for the child, the other parent
will have access to information maintained by the child’s insurer (e.g., Social Security number).
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Caretaker Application for Child-Only Reach Up (Vermont)

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Completed 17 November 2020

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