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Your application gives us information about whether you are eligible for benefits and services. These benefits are provided at public expense and you must
give true information. It may be verified with public and private agencies and businesses. You must report any changes to the information provided on this
form within 10 days of the change. If you knowingly give false information or willfully fail to report changes you may be subject to disqualification and to the
penalties listed below.
Section 8-504 of the Criminal Law Article of the Maryland Annotated Code states that:
(a) Any person who fraudulently obtains, attempts to obtain, or aides another person in fraudulently obtaining or attempting to obtain money, property,
food stamps, medical care, or other assistance to which he is not entitled, under a social, health, or nutritional program based on need, financed in
whole or in part by the State of Maryland, and administered by the state or its political subdivisions is guilty of a misdemeanor. For purpose of this
section, fraud shall include:
(1) willfully making a false statement or representation; or
(2) willfully failing to disclose a material change in household or financial condition; or
(3) impersonating another person.
(b) Upon conviction, after notice and the opportunity to be heard as to the amount of payment and how the payment is to be made, the person shall
make full restitution of the money, property, food stamps, medical care or other assistance unlawfully received, or the value thereof, and shall be
fined not more than $1,000 or imprisoned for not more than three years, or both fined and imprisoned.
Consent to Release Information:
I hereby authorize the Maryland State Department of Education Child Care Scholarship Unit (MSDE/CCS), the Maryland State Department of Human
Resources Office of Inspector General (DHR/OIG) or any entities authorized by MDSE to contact, review and obtain records maintained by any person,
partnership, corporation, association, or governmental agency for the purpose of establishing proof of my eligibility for CCS benefits. This includes but is not
limited to: employment, financial (including bank records), school/educational, rental/housing and Maryland State Income Tax records. By signing below, I
certify that I am the undersigned, I am competent to consent to this release of information and that I give MSDE/CCS permission to provide program
information by email and/or text message. A photocopy of this form is as valid as the original.
Parent Name Printed Date
Parent Signature Date
Other Parent Name (Parent/Spouse in the Household or Parent of Minor Child) Printed Date
Signature of Other Parent (Parent /Spouse in the Household or Parent of Minor Child) Date
APPLICATIONS NOT SIGNED AND DATED WILL BE RETURNED.
Electronic signatures are accepted if application is submitted through the CCS Central 2 online parent/provider portal.
Date of application must be within 45 days of submission. Do not submit redeterminations prior to 45 days of redetermination end date
Report suspected fraud of the Child Care Scholarship Program at Reportccsfraud.org
MSDE-CCSCENTRAL DOC.221.30 Revised 05/01/2021
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