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Parent/Legal Guardian (please print) Parent/Legal Guardian Signature Date
PARENT/LEGAL GUARDIAN CERTIFICATION:
(Please read carefully, check all boxes, sign and date in designated area.)
I CERTIFY THAT:
I am the parent or legal guardian of the child(ren) listed and I may be required to submit proof of such in order to receive
fee assistance.
All information submitted in this application is true and correct. Any
misrepresentation of this information may result in reclaiming any
money paid for child care and may result in prosecution under applicable State and Federal laws. See 18 U.S.C. § 1001.
I
UNDERSTAND
THAT:
I must submit proof of my continued eligibility for this program when requested.
This information is being given in connection with military funds used to reduce the cost of child care, and Military and
Child Care
Aware® of America (CCAoA)
officials may verify any information on this application at any time they deem necessary.
This program is not an entitlement program and is subject to the availability of funds, which may be discontinued at any time.
All program policies and guidelines are set forth by the funding entity’s requirements, including but not limited to sponsor status,
provider eligibility, schedule of care, number of hours of care, and more. CCAoA serves only as the program administrator. If I do not
meet the minimum requirements set forth by the funding entity, then I am not eligible for the program.
Fee assistance for which I am eligible is based on my program eligibility, income, child care tuition, age of child(ren), the
provider/program’s location, and the type of child care I select; if there are any changes to my situation, I must make CCAoA
aware of
those changes immediately.
Both parents’/legal guardians’ information must be listed on the application unless I am a single parent with sole custody.
I must select a qualified child care provider/program that meets my program’s requirements in order to participate in the fee assistance
program
. These requirements include but are not limited to: a state license and an inspection report free of disqualifying incidents. Some
programs may require a national accreditation. Programs/providers who do not meet the eligibility requirements of my program and
who are not qualified for my program will not be reimbursed. For more information on provider eligibility, please visit
http://usa.childcareaware.org/ .
A provider/program’s probation or disqualification from the fee assistance program may result due to severe non-compliances or a
change in the provider/program’s state licensing status. Fee assistance will not be issued to providers/programs who are disqualified.
In order to continue with the fee assistance program, I must choose a new eligible provider.
I must give CCAoA a minimum of two (2) weeks’ notice prior to changing child care providers/programs by submitting a CHANGE OF
PROVIDER/PROGRAM FORM
. I may not change providers more than three (3) times per year.
I may use more than one provider/program; however, CCAoA will not reimburse more than one provider/program for the same period
of time, for the same child.
If I use a back-up child care provider/program, CCAoA must reimburse the primary child care
provider/program first.
All family income of the spouse and sponsor must be reported. Any changes to the income or employment status of the spouse or
sponsor must be reported to CCAoA immediately.
I must disclose any income and additional sources of fee assistance, including but not limited to: long-term disability benefits; voluntary
salary deferrals; retirement or other pension income; other federal/state benefits; quarters subsistence and other allowances appropriate
for the rank and status of military whether received in cash or in kind; child care/fee assistance vouchers, waivers, or subsidies;
state/private child care subsidies; state/private child care scholarships; anything
else of value, even if not taxable,
that was received for
providing services or to help pay for child care services.
I must submit a copy of the Statement of Non-Availability with my application packet and when requested. If I reside within 15mi/20min
from any installation or garrison, the Statement of Non-Availability must be signed by the authorized CYSS representative at that
installation or garrison. The following are exempt: school age children, geographically dispersed Army National Guard & Army Reserves,
Wounded Warriors, and SOS sponsors.
I may not receive subsidies or fee assistance from both military-sponsored child care and the Fee Assistance Program at the same time.
All child care rates reported to CCAoA for fee assistance calculation purposes must include any offered discounts and/or promotions.
These discounts must be reported and applied up front at the time of processing.
CCAoA will only make payments directly to the child care provider/program and not to me.
The fee assistance subsidy is the difference between what the family would pay for on-post care and the community-based child care
provider’s rate, up to a specific provider rate cap. The family is responsible for the on-post child care parent fee and any amount over the
provider rate cap. For more information, see http://usa.childcareaware.org/fee-assistancerespite/military-families/army.
I am responsible for any remaining child care fees after fee assistance has been issued. CCAoA will NOT pay the full cost of child care
for approved families. Payment arrangements for the remaining fees must be made directly with my provider/program and not
CCAoA.
Attendance sheets must be completed, signed by the parent/legal guardian and child care provider, and submitted to CCAoA within 30
days of services provided. Failure to submit attendance sheets within this timeframe will result in forfeiture of payment.
For more
information on Payment Policies, please visit
http://usa.childcareaware.org/
.
The f
irst and last month payments are prorated based on the start and end date of the fee assistance approval certificate.
Fee assistance will not be backdated to any time before I submitted my application, regardless of whether my child was already in care .
I must complete my application or recertification within 90 days in order to be eligible for backdated fee assistance. If deemed eligible
for backdated payments, I must submit the attendance sheets within 30 days of when I receive my fee assistance approval.
I must notify CCAoA at least fifteen (15) calendar days before ending child care services. In cases of emergency, I will notify CCAoA
immediately (1-800-793-0324).
I have read all of the above and understand its content. I also understand that non-compliance with any of the
above may result in immediate
termination of my fee assistance and of my participation in the Fee Assistance Program and I may be required to re-pay any money paid on my behalf.
