CCS Packet

Workforce Solutions - Child Care Services (CCS)
Eligibility Requirements
Dear Parent(s)/Guardian(s);
We are pleased to provide this information and application for Child Care Services to assist you with the cost of
care for your child/ren while you work, are in training or to continue your education.
Please complete, sign and date all the forms on this packet that apply to your household and return with all the
required verifying documentation. Once the complete eligibility packet is received, a Child Care Specialist will
review the information submitted and determine if you qualify for child care services.
Eligibility Requirements
Your family may be eligible for child care assistance if:
1.
2.
3.
4.
5.
You reside in Hidalgo, Willacy, Starr County; and
You have a child(ren) under the age of 13 (or a child(ren) with disabilities under the age of 19); and
Your family’s income does not exceed 85% of the state median income (see below); and
Each child receiving child care is a US citizen or legal resident of the United States; and
The family requires child care to participate in training, education, and/or a combination of
employment activities a minimum of 25 hours per week for a single-parent family or 50 hours per
week for a two-parent family.
Gross Monthly Income
October 01, 2014 – September 30, 2015
2
Maximum Monthly
85% State Median
$3,264
3
$4,032
4
$4,799
5
$5,567
6
$6,335
7
$6,479
8
$6,623
9
$6,767
10
$6,911
Family Size
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
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1
CCS Eligibility Packet Checklist
Use the following checklist as a guide to be certain you complete the entire Child Care Services Eligibility
Packet. You may go to your nearest Workforce Solutions Career Center to use a computer, printer, and/or fax
machine free of charge. To locate the Workforce Solutions Career Center nearest you, please visit
www.wfsolutions.org
Once complete, the application and verification documents may be mailed, faxed or hand-delivered to the address below.
Mail or Hand Deliver
Workforce Solutions – Child Care Services
Workforce Solutions – Child Care Services
WFS Mission Office
WFS Weslaco Office
901 Travis St., Suite 7
1600 N. Westgate, Suite 400
Mission, Texas 78572
Weslaco, Texas 78596
Direct: (956) 519.4300
Direct: (956) 969.6100
Fax: 1.866.580.6089
Fax: 1. 866.890.5452
Hours: M-F, 8am – 5pm
PLEASE BE CERTAIN TO SIGN, DATE AND KEEP COPIES OF ALL THE DOCUMENTS YOU SUBMIT.
Child Care Eligibility Certification Application – This is your official application. You must ensure this
application is complete and accurate or your child care assistance may be denied. You must ensure that the
application:
 Is completely filled out
 Is completed in ink only (no pencil)
 Is signed and dated (the day you submit the application)
 Does not have “whiteout” corrections
Proof of Physical Address
 Current State Driver License
 Current Picture Identification Card
 Water, Light, or Gas Bill
 Texas Department of Health & Human Services Letter
Parent Identity: You must submit the following for each parent in the household to verify parent identity.
 Birth Certificates
 Social Security Cards (optional)
 Valid Driver’s License or State Issued Picture ID
Age & Citizenship –Child (ren): You must submit the following for each child in your household to verify
age/citizenship
 Birth Certificates (U.S. or its possessions)
 U.S. Passport (must be current)
 Hospital or public health birth records (U.S. or its possessions). Note: We cannot accept birth facts.
 Church or Baptismal Record (U.S. or its possessions)
 TANF, food stamp benefits, Medicaid, or other related public assistance records
“What if my child was born in the United States, but I was not?”
o Answer: Only the child receiving assistance is required to be a US Citizen or Legal Resident
“What if I do not have any of the above documents to verify age/citizenship?”
o Answer: Child Care Assistance cannot be authorized for that specific child.
Note: If you do not have any of the above mentioned documents,
please contact our office @ (956)519.4333 or (956)969.6144
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
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Child Support: You must supply the following to verify child support cooperation
 Office of the Attorney General Child Support Income Verification Form (Page 12-13)
www.childsupport.oag.state.us.tx, and/or
 Parental Responsibility Agreement (PRA) – Informal Child Support Form (Page 14)
Note: Verification of child support & paternity is required for all children in the household under 18 years of
age (Page 12)
Household Income: You must submit the following to verify your household income.
If employed and paid by check:
 Copies of last (4) check stubs for each parent in the household, and a
 Work Schedule Verification form completed by the employer for each parent (Page 7)
If new hire:
 Wage Verification form - sign the top section of the form and have your employer complete, sign and date
form (Page 6), and
 Provide copies of check stubs, if available
*In addition, please submit verification of all household members’ income.
Note: Dependent(s) over 14 years of age not attending school and is working; must report their earnings.
Note: If you or your spouse are self-employed or paid in cash (Page 8-10),
For any questions on this please contact our office @ (956)519.4333 or (956)969.6144
If participating in a Job Training/Educational Program: You must supply the following to verify your
participation in a Job Training/Educational Program.
If attending a college or university:
 Current School Schedule, and
 Current Transcript
If attending a vocational school:
 Enrollment Letter from the school, and
 School or Training Schedule Verification Form -completed by the training/education provider (Page 11)
For High School or GED Students only:
 Program enrollment form, or
 Letter from school verifying enrollment, and
 School or Training Schedule Verification Form -completed by the training/education provider (Page 11)
Child (ren) School Attendance: You must provide the following to verify attendance for all children in the
household under 18 years of age. (Page 22)
 Self-Attestation of School attendance
Child Care Automated Attendance (CCAA): You must sign and return the following to verify your understanding
of your responsibilities in using the CCAA system and to receive CCAA cards for yourself and/or up to (3) designees.
(Page 19-20)
 Parent Agreement for use of CCAA
 CCAA Primary and Secondary Cardholder Request Form
Reporting absences and attendance daily is a CCS requirement. Failure to do so will result in termination of
your child care services.
Parent Acknowledgement of Rights and Responsibilities (PARR): You must sign and return the PARR which
informs you of your rights and responsibilities while receiving this assistance (Page 15-18) , including:
 Responsibilities to report changes within 10 days of occurrence, and
 Consequences for not reporting changes as well as for fraud and abuse of program services.
Orientation to Discrimination Complaint Procedures Form: You must sign and return this Form which informs
you of your rights and procedures for filing complaints related to services received. (Page 23-24)
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
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CHILD CARE ELIGIBILITY CERTIFICATION APPLICATION
TWIST ID#:
CHILD CARE ELIGIBILITY CERTIFICATION APPLICATION
TWIST #
1.Applicant Name (First, MI, Last) / Nombre: (Inicial, apellido)
Social Security (optional) / Número
de seguro social (opcional)
Date of Birth / Fecha de
nacimento
Physical Address / Dirección del Domicilio
City / Ciudad:
Zip Code / Código postal
County / Condado
Mailing Address / Dirección postal
City / Ciudad
Zip Code / Código postal
Sex:
Sexo
Other Contact # w/Name and
Relation / Teléfono alternativo,
nombre y relación:
Family Size/Número de
miembros que componen
la unidad familiar:
Home Phone # / Teléfono del hogar
Cell Phone # / Teléfono cellular
Yes/Si
M
M
F
F
No
Do we have your consent to contact you
via text message/ Tenemos su
consentimiento para ponerse en contacto
con usted través de mensajes de texto
Are you a Veteran or Spouse of a Veteran?
Yes No
Es usted veterano o esposo/a de un
veterano? Si No
E-Mail Address
/ Correo Electrónico
Foster Youth
Yes
No
Highest Grade
Completed/Nivel de
educación
Migrant
Yes
No
Race/Raza
Hijos adoptivos Si
No
Marital Status: ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed
Estado civil: ( ) Casado ( ) Soltero ( ) Divorciado ( ) Separado ( ) Viudo ( )
Migrante
Si
No
Food Stamps
Yes
No
Recibe estampillas? Si
No
Place of Employment/Lugar de Empleo
Work Schedule/Horario de Trabajo
Hire Date/
Fecha Contratado
Other Income/Otros Ingresos
Hourly Pay Rate/
Salario por Hora
Work Phone #/ Teléfono del Trabajo
Pay Frequency/Frecuencia de Pago
Weekly
Bi-Weekly
Monthly
Bi-Monthly
Name of School or Training Institution/
Nombre de la escuela o Institución de
formación
Self Employed/Autónomo(a)
Income before taxes / Ingresos antes
de impuestos
$ __________________________
School Schedule/Horario Escolar
Tips:$_________ Bonus:$_________
Commission $__________
None
Semester Hours/Hours Semestre
Hispanic/ Latino
Y/SI
No
$ ______________
Start date/ Fecha de
Inicio
Second Parent in Household/Segundo Padre de la Casa
N/A Check N/A If Second Parent is NOT Part of the Household/ Marque N/A Si Segundo Padre NO es Parte de la Casa
2. Name of Second Parent in Household /Nombre del segundo padre que está en
Social Security (optional) / Número
Date of Birth / Fecha de
casa
de seguro social (opcional)
nacimento
Home Phone # / Teléfono del hogar
Place of Employment/Lugar de Empleo
Work Phone #/ Teléfono del Trabajo
Pay Frequency/Frecuencia de Pago
Weekly
Bi-Weekly
Monthly
Bi-Monthly
Name of School or Training Institution/
Nombre de la escuela o Institución de
formación
Cell Phone # / Teléfono celular
Self Employed/Autónomo(a)
Income before taxes / Ingresos antes
de impuestos
$ __________________________
School Schedule/Horario Escolar
Other Contact # w/Name and
Relation / Teléfono alternativo,
nombre y relación:
Hispanic/ Latino
Y/SI
No
Work Schedule/Horario de Trabajo
Hire Date/
Fecha Contratado
Other Income/Otros Ingresos
Hourly Pay Rate/
Salario por Hora
Tips:$_________ Bonus:$_________
Commission $__________
None
Semester Hours/Hours Semestre
Applicant Signature / Firma Del Solicitante:__________________________________________________
$ ______________
Start date/ Fecha de
Inicio
Date / Fecha:______________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
4
CHILD CARE ELIGIBILITY CERTIFICATION APPLICATION
TWIST #
N/A
Check N/A If You Don’t Have a Second Employment / Marque N/A Si Usted No Tiene Segundo Empleo
Place of Employment/Lugar de Empleo
Self Employed/Autónomo(a)
Work Schedule/Horario de Trabajo
Work Phone #/ Teléfono del Trabajo
Pay Frequency/Frecuencia de Pago
Weekly
Monthly
Bi-Weekly
Bi-Monthly
Income before taxes / Ingresos antes
de impuestos
$ __________________________
Other Income/Otros Ingresos
Tips:$_________ Bonus:$_________
Commission $__________
None
Hire Date/
Fecha Contratado
Hourly Pay Rate/
Salario por Hora
$ ______________
Additional Income
List any other sources of income or assistance your family receives and the amounts. Gross income including: bonuses, tips, commission, incentives
pensions, annuities, life insurance, retirement income, early 401K withdraws, lottery winnings of $600.00 or greater, taxable capital gains, dividends,
interest, rental income, public assistance payments, income from estate and trust funds, unemployment compensation, compensation income, spousal
maintenance or alimony, court settlements or judgments, social security benefits, incentives, child support, etc. must be included. Note: You will
need to provide CCS documentation for all income and/or benefits received on this list.
Source of Income/
Who Receives the Income/
Amount/
How Often Received/
Fuente de Ingreso
Quien Recibe los Ingresos
Cantida
Frecuencia lo Recibe
Name(s) / Nombre(s)
Other Household Dependents / Otros Dependiente Del Hogar
Social
Security#
Child
Birth Date
Relation
Sex
Ethnicity
(optional)
Care
Fecha de
Relación
Sexo
Raza
Numero De
Requiere
Nacimiento
Seguro Social cuidado?
(opcional)
Child with
Special
Needs Es
niño(a) con
necesidades
especiales?
SSI
3.
M
F
Y/SI
No
Y/SI
No
Y/SI
No
4.
M
F
Y/SI
No
Y/SI
No
Y/SI
No
5.
M
F
Y/SI
No
Y/SI
No
Y/SI
No
6.
M
F
Y/SI
No
Y/SI
No
Y/SI
No
7.
M
F
Y/SI
No
Y/SI
No
Y/SI
No
Grade
School
Grado
Escolar
Provider Information/Informacion del Proveedor
Day Care Name: __________________________________________
DC License #:___________________
Phone Number:_______________________
Nombre de Proveedor
Numero de Licencia
Numero de Teléfono
I understand that: (1) a person who obtains or attempts to obtain, by fraudulent means, services to which the person is not entitled may be prosecuted under applicable state and federal laws; (2)
I am entitled to be notified about my eligibility for services within 20 calendar days from the date of this application; (3) I, or my representative, may appeal denial, reduction, or termination of
services; (4) services will be provided without regard to sex, race, creed, color, national origin, or disability; (5) the information on this application is confidential. By signing this form, I am
applying for services from Workforce Solutions or their child care contractor. I give permission to Workforce Solutions or their child care contractor to contact a third party to verify income or
family size, and use the social security numbers for identification of Social Security Benefits and income. All Information provided represents a complete and accurate statement of my
family’s circumstances at the time of application. I agree to report any changes to this information within 10 business days of the change. I understand that social security numbers (SSN) are
voluntary and not a requirement to receive child care services.
Entiendo que (1)Personas que obtienen o que atentan obtener, por medio ilícito, servicios a personas que no califican pueden ser demandadas bajo las leyes federales y estatales; (2) Tengo el
derecho de recibir notificación de mi elegibilidad de servicios dentro 20 días calendarios a partir de la fecha de esta aplicación; (3) Yo, o mi representante, pueden apelar el rechazo,
reducción o terminación de servicios; (4) servicios serán dados independiente de raza, sexo, credo, color, nacionalidad, o incapacitación; (5) la información en esta aplicación es
confidencial. Al firmar esta forma, estoy aplicando para los servicios de Workforce Solutions o el contratista de cuidado de niños. Le doy permiso a Workforce Solutions o al contratista de
cuidado de niños que contacten a terceros para verificar ingresos o la cantidad en la unidad de familia, y el uso de los números sociales para identificar ingresos y beneficios de seguro social.
Toda la información proporcionada representa una declaración completa y precisa de las circunstancias de mi familia en el momento de la solicitud. Estoy de acuerdo en reportar cualquier
cambio a esta información dentro de 10 días hábiles posteriores al cambio. Entiendo que el número social es voluntariado y no es un requisito para recibir servicios de cuidado infantil.
Applicant Signature / Firma Del Solicitante: _________________________________________________
Date / Fecha: _______________
CCS Representative / Firma de Representante de CCS: ___________________________________________
Date / Fecha: ________________
Office Use Only:
Eligibility Start Date_____________________ Eligibility End Date
___________________
Family Size: _____________ 85% SMI: _____________________ Total HH Income: _______________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
5
Child Care Services
WAGE VERIFICATION FORM
TWIST #_____________
To be completed by employee:
Release of Information
I, _______________________________, authorize the release of the following information to Workforce Solutions. I
understand that additional information may be required from my employer and/or clients.
Signature: _________________________________
SSN: (Optional) ________________________________
To be completed by Employer:
Do you currently employ the individual named above?
Yes
No
Employee’s Job Title: ___________________________ Duties: ___________________________________
Pay Frequency:
Daily
Weekly
Bi-Weekly
Semi-monthly
Monthly
Hourly rate of pay: $ _________
Number of hours worked per week: ____________________
How is employee paid?
Cash
Check
Direct Deposit
Other Income?
Bonus/Incentive
Tips
Commission
Is overtime offered:
Frequently
Rarely
Never
Work Schedule
Please mark the days and times employee is scheduled to work each week. (Ex. 8am – 5pm)
Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Times
Comments: ________________________________________________________________________________
On the chart below, please list the employee’s wages for the last FOUR pay periods.
Pay Date
Pay Period Dates
Hours Worked
Gross Wages
From:
To:
1.
$
2.
$
3.
$
4.
$
FOR NEW EMPLOYEES
Business/Employer Name:
Date Hired:
Address:
Date of First Paycheck:
Phone #:
FOR EMPLOYEES NO LONGER WITH THE COMPANY
Employer Representative Name:
Last Date of Employment:
Title:
Date Final Paycheck Received:
Date:
The information above pertains to the employee’s eligibility for Child Care Services and is subject to validation against
state and federal databases, in-person interviews, and/or submittal of additional supporting documentation. I acknowledge
that the information I have provided is true and correct. I understand that a person who provides false or incorrect
information for someone to obtain or attempt to obtain, by fraudulent means, services to which the person is not entitled
may be prosecuted under applicable state and federal laws. Subject to verify information provided.
_______________________________________________
Employer Representative Signature
For Office Use
___________________________
Date
Telephone verification completed by: _____________________________
Date: ______________________
Representative Name, Title: ____________________________________
Phone: _____________________
Comments: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Deductions
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
6
Complete Work Schedule Verification Form
(To be completed by employer)
Note to employer: Your employee is applying for or is currently receiving child care assistance
with Workforce Solutions -Child Care Services. To determine eligibility, we must receive a
detailed summary of working hours. Please complete the following information:
Employee Name:
________________________________________________________________
TWIST #/SSN # (optional): _________________________
Phone #: ______________________
TO BE COMPLETED BY EMPLOYER:
Company Name:
___________________________________________________________
Company Address:
___________________________________________________________
___________________________________________________________
Please indicate the shift hours for the employee for each day listed (ex: Monday 9am-5pm):
Monday:
_________________
Friday:
_________________
Tuesday:
_________________
Saturday:
_________________
Wednesday:
_________________
Sunday:
_________________
Thursday:
_________________
Does this schedule vary?
Yes
No
If yes, please explain in detail:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
SIGNATURE (MUST BE SIGNED BY EMPLOYER)
__________________________________________________________________________________________
Person Completing This Form (Please Print)
Title & Phone#
_________________________________________________________________________________________
Signature
Date
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
7
WORKFORCE SOLUTIONS-CHILD CARE SERVICES
SELF-EMPLOYMENT
For the purpose of child care eligibility, parents will be considered to be self-employed if their wage records do
not reflect at least one of the following deductions: Federal Income Tax withholdings, Social Security or
Medicare taxes. The federal minimum hourly wage will be applied to the self-employment net income to
determine the parent’s work hours.
Acceptable Documentation for Verification of Self-Employment Status
One of the following forms of documentation will be required for initial verification and at every
recertification of established self-employment enterprises:
1. Federal income tax forms or quarterly income reports, such as:
 Form 1040; or
 Schedule C, F, or SE federal income tax returns for the most recent tax year; OR
2. One of the following documentations can be used to document the existence of the business:
 Property titles, deeds, or rental agreement for the place of business;
 Recent business bank, phone, utility, or insurance bill; or
 Recent state sales tax return, AND
The following documentation along with Attachment A-Business Income Statement will be required to determine income
eligibility for child care services:
1. Documentation that provides information on the amount of income generated and the associated
business expenses and contains:
 Customer names and contact information (if available);
 Dates and locations of services provided;
 Amounts received; AND
2. Business expense receipts that substantiate the expenses to be deducted from the gross income, when
applicable.
INDEPENDENT CONTRACTOR
In certain cases a parent may not be claiming “self-employment” but rather “independent contractor”.
A parent who may claim to be “independent” is someone who submits:
 Checks from a business or an individual that does not contain deductions
The following documentation along with Attachment A-Business Income Statement will be required to
determine income eligibility for child care services:






Checks from the business/individual containing the amount paid – the check should have the name of
the business/individual as well as made out to the name of the parent
Copies of the checks from the business/individual that have been processed (i.e. cashed by the parent) to
demonstrate actual pay
Bank statement from the parent showing deposits in the amount of the checks paid
Work Verification Form (Page 5)
Invoices
Work orders
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
8



Customer contracts
Tax Records
List of Customer Contact
PAID IN CASH
The following documentation along with Attachment A-Business Income Statement will be required to
determine income eligibility for child care services:
 Receipts from the parent to the person/business showing the amount the parent was paid for the work =
the receipt should show the name of the person/business whom the parent received the payment from,
the work performed, the date of the payment and location where work was performed
 Receipts for expenses the parent spent to perform the work - inclusive of expenses such as fuel costs,
transportation, etc.
 Wage Verification Form (Page 5)
 Information on the Internet
 Business Card
 Ledger
 County Registration
EXPENSES
Expenses are your costs of doing business.
Examples of expenses are supplies, repairs, rent, utilities, seed, feed, business insurance, licenses, fees,
payments on principal of loans for income-producing property, capital asset purchases (such as real property,
equipment, machinery, and other durable goods and capital asset improvements), your social security
contribution for people who worked for you, and labor (not salaries you pay yourself). If you claim labor costs,
list each person and the amount you paid them. If you have any other kinds of business expenses, be sure to list
them and the date they were paid. If you are in doubt, bring proof of the expense and ask your worker.
WORK HOURS
CCS families are required to work an average of 25 hours per week for a single- parent household, or a
combined 50 hours per week for a 2-parent household. CCS staff will calculate the amount of hours worked per
week based on the net monthly income, the net income will be divided by the current minimum wage hourly
rate to determine eligibility.
CHILD CARE VERIFICATION REVIEW PROCESS
Child Care Services staff will review TWC and other state databases during all child care eligibility
certifications. If discrepancies are identified during the review process, staff will continue with the intake
certification; however, customers will be notified in writing that they are required to assist in resolving
discrepancies identified. Customers will be allowed 15 calendar days to report necessary changes to the
appropriate agency to resolve all discrepancies. If the customer does not report to the appropriate agency to
resolve all discrepancies within 15 calendar days, the customer will be mailed a 15 day termination of child care
services notice.
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
9
Attachment A: Business Income Statement
1. Name of Person Having Self-Employment Income
Nombre de la persona que tiene ingresos de negocio propio___________________________________________________________
2. Give the number of months covered by this income statement.
Dé el número de meses que cubre esta declaración de ingresos...................................................................
3. Describe what you did to earn this money:
Describa lo que hizo para ganarse este dinero: ______________________________________________________________________
4. List your business income and expenses (IMPORTANT: Attach receipts, invoices, or other verifying papers).
Anote los ingresos y gastos de su negocio (IMPORTANTE: adjunte recibos, facturas u otros comprobantes).
Date
Fecha
Business EXPENSES
GASTOS
Total Business Expenses ----->
Amount
Cantidad
$
Date
Fecha
Business INCOME
INGRESOS
Total Business Income ------->
Total Business Expenses ----->
Adjusted Business Income --->
Amount
Cantidad
$
$
The above information is true, correct, and complete to the best of my knowledge. I understand that giving false
information to the CCS contractor may result in my childcare being reduced, denied, or terminated up to and including
prosecution for fraud.
Print Name
Date
Signature
TWIST ID
Attach …… to verify self-employment/business ownership.
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
10
School or Training
Schedule Verification Form
(To be completed by School or Training Institution)
Case Name: __________________________________
TWIST #/SSN (optional): ___________________
Student Name: ________________________________
Phone #: ________________________________
Note to training institution: Your student is applying for or is currently receiving child care assistance from
Workforce Solutions – Child Care Services. To determine their eligibility, we must receive a detailed summary
of the student’s class/training schedule and attach enrollment form. Please complete the following information:
Training Institution Name: ____________________________________________________________________
Address: __________________________________________________________________________________
_________________________________________________________________________________________
Student’s Date of Enrollment: ________________________
Projected End Date: ___________________
Please indicate the student’s class schedule for each day listed (ex: Monday 9am – 5pm)
Monday:
_________________
Friday:
_________________
Tuesday:
_________________
Saturday:
_________________
Wednesday:
_________________
Sunday:
_________________
Thursday:
_________________
Does individual attend school regularly, and are they working toward successful completion?
If no, please explain (comment is optional):
Yes
No
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SIGNATURE (Must be signed by SCHOOL or TRAINING INSTITUTION)
__________________________________________________________________________________________________
Person completing this form (please print name)
Title & Phone #
__________________________________________________________________________________________________
Signature
Date
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
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IMPORTANT
Child Support Information
Eligibility requirements state that in order for you to be eligible for services, you must prove that you are
actively seeking child support (formal or informal agreements) for all children living in your household under
the age of 18. It will be your responsibility to provide verification of compliance with this requirement in order
to be considered eligible for child care assistance.
If you do not have an informal arrangement with the non-custodial parent(s), you must:
 Locate the Office of the Attorney General nearest you or apply online at www.oag.state.tx.us.
Verification of the application or payment history will be required by Child Care Services in order for
services to be authorized or re-authorized.
 Proof of Paternity
 Copies of Birth Certificate
 Acknowledgement of Paternity
 Office of Attorney General-Form 1825
 Informal Child Support Agreement Form
 Copy of Child Support Interactive (print screens)
 Copy of divorce decree of section on child support
 Letter from attorney, judge, or courts on child support
 Child Care Services - Exceptions to Parent Responsibility Agreement Requirements
Please attach your child support documentation here
and return to Child Care Services.





Acceptable documents:
Form 1825 with Payment History
Child Support Income Verification Form
Payment Status
Payment Record
Child Support Interactive (CIN) Form
(Please attach all child support documentation for all children in household)
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
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Child Support Interactive (CIN) Form
To: Child Care Services
Case where the absent parent is not included in the Birth Certificate will require a Form 1825 to be completed by the
OAG office.
Custodial Parent: _______________________________________
Non-Custodial Parent: ___________________________________
Mutual Child (ren): __________________________________
DOB: _________________
__________________________________
DOB: _________________
__________________________________
DOB: _________________
By signing below I acknowledge that the attached Child Support Interactive Print Screen belongs to me and my children. I
understand that a person who obtains or attempts to obtain, by fraudulent means, services to which a person is not entitled
may be prosecuted under applicable state and federal laws.
__________________________________________________________________________________________
To: Child Care Services
Case where the absent parent is not included in the Birth Certificate will require a Form 1825 to be completed by the
OAG office.
Custodial Parent: _______________________________________
Non-Custodial Parent: ___________________________________
Mutual Child (ren): __________________________________
DOB: _________________
__________________________________
DOB: _________________
__________________________________
DOB: _________________
By signing below I acknowledge that the attached Child Support Interactive Print Screen belongs to me and my children. I
understand that a person who obtains or attempts to obtain, by fraudulent means, services to which a person is not entitled
may be prosecuted under applicable state and federal laws.
Parent Signature: ______________________________ Date: ________________
SSN/TWIST ID: ______________________________ CCS Specialist: _____________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
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Parent Responsibility Agreement
Informal Child Support Form
Parent Name (Print Name Here)
Twist #
State law requires that any family receiving child care assistance comply with the Parent Responsibility Act. This Act
includes receiving child support for each individual child in the household. Failure to comply with this requirement
will result in termination of services.
When to use this form: This form is to be used ONLY when there is an informal ongoing child support arrangement
between the custodial and the absent parent(s); which paternity has been established, not filed with the Attorney General
Office or Private child Support Agency. (i.e., not working with the Office of Attorney General).
Informal: The absent parent is giving you support payments instead of paying through the Office of Attorney General.
Who completes this form: This form is to be completed by the custodial parent and by the absent parent, who is NOT
living in the household.
IMPORTANT: if any children in the household have informal arrangements with different absent parents, a
separate form must be completed with each absent parent. Please make copies of this form for each child’s absent
parent to complete and sign. Child care assistance will be terminated or denied if we do not receive this
documentation.
Custodial Parent Name:
Phone Number:
Custodial Parent Physical
Address:
Absent Parent Name:
Phone Number:
Absent Parent Physical
Address:
City
State
Zip
SSN (optional)
I, the absent parent, hereby attest that I am the father to the children listed below and I provide child support payments to
their custodial parent.
Child Name (First and Last Name)
Total Child Support ($)
How Often
Weekly, Bi-Weekly, or Monthly
__________________________________________________________________________________________________________
Custodial Parent Signature
Date
__________________________________________________________________________________________________________
Absent Parent’s Signature
Date
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
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PARENT ACKNOWLEDGEMENT OF RIGHTS AND
RESPONSIBILITIES FOR CHILD CARE SERVICES
Parent Name: _____________________________________
TWIST ID: _____________
Please read the information on this form carefully before you and your spouse (if applicable) sign and date. Contact your
child care worker immediately if you have any questions regarding the information or requirements on this form. Please
understand Child Care Services can end at any time if you become ineligible, your eligibility cannot be determined
or funding has been exhausted.
PARENT ENROLLMENT
I understand the availability of child care services, the process for accessing those services, my rights and responsibilities, and the
process to receive and continue the child care services. My spouse (if applicable) and I must:
 Be in training, education or employment activities for at least 25 hours a week for a single family, and 50 hours a week
for a two parent household.
 Be within income guidelines for my family size.
 Reside within Hidalgo, Willacy, & Starr County.
 Sign, date and submit all required forms and documents to CCS at least 10 work days before my eligibility end date.
 Report loss of employment within 10 calendar days of occurrence. I understand that I may be eligible for a 28 day job
search activity once a year (October to September).
 Select the child care arrangement that my family will be using. I was given information about types of child care;
licensed, registered, relative and those with providers with quality ratings.(Not available to CPS referred parents)
I understand the requirements of the child care facility, and
 I will pay my parent share of cost (parent fee) to the provider at the first of each month or before services
are rendered.
 I will meet the enrollment requirements and policies of the child care facility unless the policies directly conflict with
those of CCS.
 I will report to Child Care Services within 3 business days, instances in which an attempt to record attendance in CCAA
is denied or rejected and cannot be corrected at the provider site. And that failure to report such instances will result in
an absence counted against my child’s attendance.
 I will contact the provider or my child care specialist if my child is/will be absent for five (5) consecutive days & must
ensure absences are recorded in CCAA. I understand a fifteen (15) day notification is not required, and child care will not
continue, during an appeal if the care was terminated due to not making this contact.
 I will provide information including health and immunization records, authorization to secure medical assistance, and
parent contact information to be used in case of an emergency.
 I will abide by the child care facilities business hours and pay charges incurred if I am late picking up my child.
 I will report to Texas Department of Family & Protective Services Child Care licensing office any possible violation of
licensing standards at the child care facility. If I need child care on any of the provider’s authorized CCS paid holidays, I
will make and pay for my own arrangements.
 I will make and pay for other child care arrangements when I am no longer eligible for child care services.
 I understand childcare providers are prohibited from denying a child care referral based on the parent’s income status,
receipt of public assistance or the child’s Texas Department of Family and Protective Services status.
 I understand providers cannot charge fees to parents receiving child care services that are not charged to parents who are
not receiving child care services.
 I understand I am allowed no more than three provider transfers per year based on anniversary date. Transfers are
effective on the first of the following month. Exception to the transfer limit and effective start date are allowed due to
child safety issues, provider corrective action or other extenuating circumstances.
I release the Workforce Solutions-Child Care Services Contractor, Lower Rio Grande Valley Workforce
Development (LRGVWD) Board, and Texas Workforce Commission (TWC) from any responsibility for the quality
of the child care services my child may receive from the facility of my choosing.
Parent Signature: __________________________________________ Date: ______________________
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R 6.29.15
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PARENT RESPONSIBILITYAGREEMENT (PRA)
(not applicable to TDFPS and Choices Referrals)
I understand that my spouse, if applicable, and I:
 Must establish paternity for my child (ren) and obtain child support for my child (ren).
 Must not use, sell or possess marijuana or a controlled substance, or abuse alcohol.
 Must make sure that each family member younger than 18 years of age attends school regularly, unless the child has a
high school diploma or a GED credential, or is specifically exempt from school attendance by Texas Education Code
(25.086).
 Understand that the statements listed above will be reviewed at certification and recertification.
 Understand that failure of the parent or caretaker to comply with the provisions of this agreement may result in denial of
child care services.
PARENT SELF-DECLARATION
I declare that, since I was last determined to be eligible to receive child care services, my spouse (if applicable) and I have:
Note: If 2nd parent is not in the household, please check the N/A box.
Parent
Spouse
(N/A)
Used, sold, or possessed marijuana or other controlled substances
Yes
No
Yes
No
If “yes,” I am currently participating in or have completed a drug rehabilitation program and have attached documentation from the
program.
Yes
No
Yes
No
I have abused alcohol.
Yes
No
Yes
No
If “yes,” I am currently participating in or have completed an alcohol rehabilitation program and have attached documentation from
the program.
Yes
No
Yes
No
Spouse Signature (if applicable):__________________________________
Date: _______________________
PARENT SHARE OF COST (Parent Fee)
(not applicable to TDFPS, Choices, and SNAP Referrals)







I shall report to CCS and pay other child care subsidy I receive from another agency to the child care provider.
I understand that the parent fee amount is based on my gross monthly income, the number of household members, and
the number of children I have enrolled in care.
I shall pay my parent fee even if my child is absent or is not there for the full month.
If I do not pay the parent fee amount specified on the CCS Case Summary Information Form timely, my child care
services may be terminated.
I shall pay the parent fee to my child care provider before services are provided. I also understand that my child care
services will be discontinued on the third (3rd) late parent fee provider report within a six month period.
I understand a mandatory waiting period of thirty (30) days will be required before I can reapply or be placed on the
waiting list for child care assistance after my child’s enrollment has been denied, reduced, suspended or terminated for
nonpayment of the parent fee.
I understand parent fee changes due to a change in the family’s gross monthly income; the new parent fee will not be
effective until the first calendar day of the following month.
PARENT RIGHTS
I understand that I have the following rights:





To request a Temporary Medical Incapacitation up to 60 days for a medical leave if I submit medical documents from
my employer verifying dates of absence from and return to work.
To appeal a denial, reduction, or termination of services.
Note: Does not apply to parents who have children in in-home CPS cases and did not request child care.
To have my personal information used to determine eligibility kept confidential.
To receive services without regard to race, sex, color, national origin, age, political beliefs, religion, or disability.
To be notified in writing at least 15 calendar days before the denial, reduction, or termination of child care services.
Parent Signature: __________________________________________________________ Date:___________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
16
PARENT AWARENESS
I shall be in training, education or employment activities at least 25 hours a week for a (1) parent household or at least a
combined 50 hours a week for a (2) parent household. I understand that failure to comply with all Child Care Services
Requirements, failure to report changes in my case within 10 calendar days of occurrence, and/or failure to provide true and
correct information in my case may result in possible criminal prosecution. My case may be referred to the Local Law
Enforcement Office, District Attorney’s Office (DA) and/or Office of Investigation (OI) for potential prosecution. I will also be
required to pay back 100% of the money that was paid to my provider during the period of ineligibility. I will report the
following within 10 calendar days of when the change occurs:





Attendance in training, in school, or if my job stops or falls below the required number of hours per week.
Total amount of income changes, including raises, overtime, bonuses, incentive pay, commission, or an increase in child
support or other non-employment income and/or benefits (such as TANF or SSI).
Marriage, divorce or a change in the number of family members living with me.
Receipt or the award of any child care funds from other public or private entities; or
Other changes that may affect the child’s eligibility or parent share of cost for child care.
REPORTING FAMILY INCOME
I understand that I must report the following income on the CCS Eligibility Certification Form and must report changes to any of
these income sources within 10 calendar days of occurrence for purposes of determining eligibility and the parent share of cost:

Total gross earnings.

Net income from self-employment

Pensions, annuities, life insurance, and
retirement income, and early withdrawals
from a 401(k) plan not rolled over within 60
days of withdrawal




Taxable capital gains, dividends, and interest
Net rental income
Public assistance payments
Income from estate and trust funds


Unemployment insurance
Worker’s compensation income, death benefit
payments, and/or other disability payments
Lottery payments of $600 or greater.



Spousal maintenance or alimony
Child support
Court-settlements or judgments; and

I understand a mandatory waiting period of thirty (30) days will be required before a parent can reapply or be placed on the
waiting list for child care assistance after eligibility was terminated due to failure to report to the Child Care Contractor, within
10 calendar days of occurrence, any changes in the family’s circumstances that would render the family ineligible for subsidized
care. I understand that the information I provide to Workforce Solutions-Child Care Services to determine my eligibility is
subject to validation through cross-checks against state and federal databases; and that I may be asked to provide original
documents and participate in face-to-face interviews to verify identity and eligibility for child care services. Failure to comply
with this requirement will constitute a voluntary discontinue.
PARENT ELIGIBILITY END DATE
I understand that in order to continue to receive child care services, I must provide all Child Care Services required forms and
documents along with all household income information to Workforce Solutions- Child Care Services at least 10 work days before my
eligibility redetermination end date or my child care may be terminated.
Parent Signature: __________________________________________________
Date: ______________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
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APPEALS
I understand that participating in Child Care Services grants me the right to file a complaint regarding my child care services. I
will be provided with an opportunity for an informal resolution in an attempt to resolve the issue. If I am not satisfied with the
informal resolution, a Board hearing may be scheduled.
Appeals:
 I understand I have the right to appeal denial, reduction, or termination of services. This does not apply to
parents who have children in in-home CPS cases and did not request child care.
 You have 14 calendar days from the mailing date of the determination letter of an adverse action, such as a
termination of services, to file an appeal with Workforce Solutions –Lower Rio Grande Valley Workforce
Development (LRGVWD) Board requesting a review.


Your appeal must be submitted in writing and include:
Your name, mailing address, and phone number





A copy of the determination letter (if applicable), and
A brief justification of your appeal request
The Board will provide an opportunity for an informal resolution in an attempt to resolve the issue.
If you are not satisfied with the informal resolution, a Board hearing will be scheduled.
You have the right to have a representative during the informal resolution and at the Board hearing. Your
representative may include an attorney (at your expense), friend, co-worker, or family member. If you choose to
have a representative during the informal resolution and/or Board hearing, you must submit a written authorization.
I read and understand all the requirements stated above and all my questions have been answered.
Parent Signature: ________________________________________________ Date: ______________________
CCS Representative Signature: _____________________________________ Date: ______________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
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PARENT AGREEMENT FOR USE OF THE
Child Care Attendance Automation (CCAA) System
This policy requires that parents understand and comply with the requirements to use the CCAA card to report daily
attendance and absences.
I agree to the following:
1. I will use my CCAA card daily to report my child’s attendance and absences. Attendance can be reported at a
point of service (POS) machine or through an Interactive Voice Response (IVR) telephone system at my child care
facility.
2. I understand that my child care services may be terminated if I do not use my CCAA card to record attendance.
3. I shall record attendance when dropping off and when picking up my child from my child care provider.
4. I shall report to my Child Care Specialist within 3 business days, instances in which mine or my secondary card
holder’s attempt to record attendance in CCAA is denied or rejected and cannot be corrected at the provider site. I
understand that failure to report such instances may result in an absence counted toward the maximum 45 paid
absences per year.
5. I understand I can designate up to three (3) individuals who will assist me in dropping off or picking up my
children from my provider, as secondary cardholders to report attendance and absences on my behalf.
Note: Secondary cardholders must be at least sixteen (16) years old, unless the individual is the child’s parent.
6. I shall NOT assign the owner, director, or employee of the child care facility as a secondary cardholder.
7. I understand that giving my CCAA card or PIN to anyone including the child care provider is a CCAA Violation
and my child care services may be terminated.
8. I shall inform my secondary cardholder of the CCAA requirements and I am responsible for any misuse of the
attendance card by my secondary cardholder(s).
9. I shall contact my Child Care Specialist if I do not receive my CCAA card within 10 days of receiving child care
assistance.
10. I shall contact my Child Care Specialist immediately if my CCAA card is lost, stolen, misplaced or damaged.
11. I agree to report misuse of the CCAA cards and PINs to Workforce Solutions – Child Care Services immediately.
12. I understand that my child care services may be terminated if I exceed 45 paid absences per anniversary year.
These absences include vacation, illnesses and Z-Days (a Z-Day is defined as an authorized care day for which no
activity was reported by the parent through the CCAA system). The forty-five days per year, begins on the enrollment
or anniversary date. Note: Enrollment/anniversary dates are child-specific and may vary for each child in care.
13. My child will not be allowed to receive child care services or be placed on the wait list for thirty
(30) days after his or her services have been terminated due to five consecutive absences without parent
notification or if I exceed the 45 paid absences. Child Care Services will notify me when my child reaches 50%,
and 75% of the allowed absences.
14. I may request a waiver to continue care if 25 out of 45 absences are due to illness or extenuating circumstances and
I can provide CCS with verifiable documentation.
Parent Signature: ___________________________________________
Date: ______________________
Parent Print Name: _________________________________________
TWIST #/SSN(optional): _______________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
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PARENT AGREEMENT FOR USE OF THE
Child Care Attendance Automation (CCAA) System
To report attendance…you or your secondary cardholder must:
1. Swipe your card.
2. Key in your PIN and press Enter.
Choose Attendance Type (1 = Check-in, 2 = Check-out, 3 = Previous Check-in, 4 = Previous Check-out)
Note: Previous Check-in and Check-out allows you to “backdate” attendance for the current or previous day. When this
feature is used for a previous Check-In, you must make sure to enter the correct date and time. If this is done incorrectly,
your CCAA will lock out and you will not be able to swipe for five (5) days. These non-swipes will be counted as absences.
Your childcare services will be discontinued when you reach 45 absences.
3. Key in the Child Number and press Enter.
4. Repeat for each child. When finished, press Enter again.
To report absences… you or your secondary cardholder must:
1. Swipe your card.
2. Key in your PIN and press Enter.
3. Choose 5 = Absence Day.
4. Select Absence Type and press Enter.
5. If not a General Absence type, select a Specific Reason.
6. Key in the Child Number and press Enter (obtain child # in your case summary form)
7. Repeat for the next child. When finished, press Enter again.
To report attendance and absences in homes or facilities where there is no POS device, you or your secondary
cardholder must use the Interactive Voice Response (IVR):
1. Call 1-866-960-6496 from the provider’s phone.
2. Enter your card number.
3. Enter your PIN.
4. Follow the instructions.
You or your secondary cardholders are responsible for making sure attendance is approved for the day by:
1. Checking the message on the POS machine or receipt after each swipe to see if it is approved.
 If the response is denied you must inform your provider.
 If the response is 'Store and Forward' (SAF), you must notify the provider that the transaction was SAF, and
 The provider will check at the next transaction to see if transaction was successful.
2. If using an IVR, you must listen to the IVR message after each recorded attendance to confirm attendance is
approved and follow the same steps above if denied.
3. If attendance is not approved through the POS or IVR for three (3) consecutive days, you will need to notify your
CCS worker. Failure to report this may result in absences counted toward the maximum 45 paid absences.
4. To replace a lost, stolen, or damaged card, you must call CCS and report it immediately. Failure to do so will
cause your child to accumulate absences.
5. To reset a PIN, you must call the Child Care Attendance Card Customer Service number (1-866-960-6496).
6. When you or your secondary cardholder first receives the CCAA card, please call 1-866-960-6496 to select a
personal identification number (PIN). You will need to enter the 16-digit card number and the cardholder’s date of
birth to establish the PIN.
By signing below I acknowledge that I have read and understand my responsibilities as a Child Care Services
customer. I understand that if I violate the CCAA requirements my child care services may be terminated and I
may be prosecuted for fraud.
Parent Signature: ___________________________________________
Date: ________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
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Child Care Attendance Automation (CCAA)
Primary and Secondary Cardholder Request Form
As the parent/caretaker you may request up to 3 different cardholders in addition to you, the primary
cardholder. Please complete this form and fax to your child care worker immediately if you have a change in
card holder or if your card is lost or stolen. Additional cards will not be ordered or reissued if the information
below is incomplete and the signature is missing. Parents/Caretakers and secondary cardholders must keep their
CCAA cards and PIN in their possession. Sharing or leaving the CCAA card and PIN with anyone else
including the child care provider is a violation of the CCAA Requirements and as a CCS customer, you and
your provider may be subject to adverse action.
Primary Card Holder Name: _________________________________
Phone #: _____________________
TWIST #/SSN(optional): ___________________________________
Do you have your CCAA Card?
Yes
No
Please complete the following section for current and new secondary cardholders.
Note: If applicable, list ALL secondary cardholders and indicate if they already have a card or if they need a
replacement card.
Be aware that if you do not list your secondary cardholders below, their cards will be inactivated.
Please ensure that this form is completely filled out.
Secondary Card Holder #1:
Has Card
Needs Card
Name: ___________________________________________________
Gender:
Male
Female
Date of Birth: ________________________Relationship to you: _________________________________
Secondary Card Holder #2:
Has Card
Needs Card
Name: ___________________________________________________
Gender:
Male
Female
Date of Birth: ________________________Relationship to you: _________________________________
Secondary Card Holder #3:
Has Card
Needs Card
Name: ___________________________________________________
Gender:
Male
Female
Date of Birth: ________________________Relationship to you: _________________________________
Primary Card Holder Signature: _________________________________
Date: __________________
Primary Card Holder Mailing Address: _______________________________________________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
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SELF- ATTESTATION OF SCHOOL ATTENDANCE
To Parent: Please complete this form and return to Child Care Services. Please do not forward to school.
I understand that: (1) a person who obtains or attempts to obtain, by fraudulent means, services to which the person is not
entitled may be prosecuted under applicable state and federal laws; (2) services will be provided without regard to sex,
race, creed, color, national origin, or disability;
By signing this form, I am applying or re-applying for services from Workforce Solutions Child Care Services. I give
permission to Workforce Solutions Child Care Services to contact the school to verify my child’s school attendance.
To parent/guardian: The parent responsibility agreement (PRA) requires that each parent/guardian shall ensure that each
family member younger than 18 years of age attends school regularly, unless the child has a high school diploma or a
GED credential or is specifically exempt from school attendance by Texas Education Code (25.086).
Case name/Name of parent
TWIST ID.
Address
#1) Name of Child: _______________________________________Date of Birth :______________________Grade:___________
Is this child attending school regularly?
Yes
No
Name of school:________________________________________________________________________________________
School Address/Telephone number:_________________________________________________________________________
Hours child is in school (Ex: M-F, 8a-4p): ____________________________________________________________________
#2) Name of Child: _______________________________________Date of Birth :______________________Grade:___________
Is this child attending school regularly?
Yes
No
Name of school:________________________________________________________________________________________
School Address/Telephone number:_________________________________________________________________________
Hours child is in school (Ex: M-F, 8a-4p): ____________________________________________________________________
#3) Name of Child: _______________________________________Date of Birth :______________________Grade:___________
Is this child attending school regularly?
Yes
No
Name of school:________________________________________________________________________________________
School Address/Telephone number:_________________________________________________________________________
Hours child is in school (Ex: M-F, 8a-5p): ____________________________________________________________________
Parent Signature:_______________________________________________
Date: __________________
Parent Print Name: _____________________________________________
Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
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LOWER RIO GRANDE VALLEY WORKFORCE DEVELOPMENT BOARD
FORMULARIO PARA LA ORIENTACIÓN A LOS PROCEDIMIENTOS DE QUEJA
DE DISCRIMINACIÓN
(29 CFR Part 38)
Este Formulario para la Orientación a los Procedimientos de Queja de Discriminación explica los procedimientos de queja de discriminación
para los programas y los servicios mencionados administrados en el Local Workforce Development Area por el Workforce Development
Board y sus contratistas:
Workforce Innovation and Opportunity Act (WOIA) Temporary Assistance
for Needy Families (TANF) / CHOICES
Supplemental Nutrition Assistance Program Employment & Training (SNAP E&T)
Child Care Services (CC)
Trade Adjustment Assistance (TAA) and Trade Readjustment Allowances (TRA)
RECIPIENTE DEL APOYO FINANCIERO FEDERAL ES:
LRGV Workforce Development Board
3101 West Business 83
McAllen, TX 78501
Oficial de Igualdad de Oportunidades (EO): Robert Barbosa
Número telefónico: (956) 928-5000
Relay Texas: 1-800-735-2989/ TTY 1-800-735-2988 (Voz)
El LRGV Workforce Development Board (el Board) resolverá quejas de la igualdad de oportunidades de una manera justa y expediente. Se prohiben los
actos de internamiento, de interferencia, de la coerción, de la discriminación, o de la represalia hacia los denunciantes que ejercitan sus derechos de
presentar una queja conforme a este procedimiento. Este procedimiento se aplica a todos los aspirantes y participantes que tengan causa para
presentar una queja de la discriminación relacionada con las actividades o los programas administrados por el Board. Si tiene una queja de la igualdad
de oportunidades referente a cualquiera de estos programas, puede presentar su queja oficial por escrito al Oficial de EO del Board o del contratista,
como sea apropiado.
Después de que se haya recibido su queja de la igualdad de oportunidades, el oficial del EO le notificará del paso siguiente en el proceso de la queja.
Mientras desea perseguir su queja, el Board o el contratista seguirá los pasos descritos abajo. Debe estudiar el procedimiento de queja de la
discriminación cuidadosamente, y si se siente que los pasos requeridos no se están siguiendo, póngase en contacto con el oficial del EO. Recuerde
que si se siente que no le están proporcionando bastante ayuda en cualquier etapa del proceso de la queja, usted debe ponerse en contacto con:
Texas Workforce Commission (TWC)
Equal Opportunity Monitoring
101 E. 15th St., Room 242-T
Austin, TX 78778-0001
Números telefónicos:
512-463-2400
Relay Texas: 1-800-735-2989
TTY 1-800-735-2988 (Voz)
LA IGUALDAD DE OPORTUNIDADES ES LA LEY
El destinatario de asistencia financiera del Gobierno Federal tiene prohibido por ley discriminar, con base en los conceptos a continuación: discriminar a
cualquier persona en los Estados Unidos por motivos de su raza, color, religión, sexo, origen nacional, edad, incapacitación, afiliación o ideología
política; discriminar a cualquier beneficiario de programas que cuenten con apoyo financiero a tenor del Título I de la Acta Fuerza Laboral de Innovacion y
Oportunidad (Workforce Innovation and Opportunity Act o WIOA), por motivo de la ciudadanía o calidad migratoria del beneficiario en tanto inmigrante
legalmente autorizado para trabajar en los Estado Unidos; o por motivo de su participación en cualquier programa o actividad que cuente con apoyo
financiero a tenor del Título I de la WIOA. El destinatario de tal asistencia no debe discriminar en ninguno de los conceptos a continuación: en decidir
quiénes han de ser admitidos o tener acceso a cualquier programa o actividad que cuente con apoyo financiero a tenor del Título I de la WIOA; en la
provisión de oportunidades en tal programa o actividad y en el trato a cualquier personal con respecto al programa o actividad; o en la toma de
decisiones de empleo en la administración de tal programa o actividad o con respecto al mismo.
Qué hacer si usted cree haber sido discriminado/a: Si cree haber sufrido discriminación en un programa o actividad con apoyo financiado a tenor
del Título I de la WIA, puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad
de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el Director, Civil Rights
Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, D.C. 20210. Si presenta su queja con el destinatario de
asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en la más temprana
de las dos fechas) antes de presentar su queja al CRC). Si el destinatario de asistencia federal no le entrega un Aviso de Acción Definitiva por escrito
dentro de los 90 días de la fecha de presentación de su queja, usted no tiene obligación de esperar a que el destinatario le expida dicho Aviso para
presentar una queja con el CRC. Por otra parte, la queja con el CRC debe presentarse dentro de los 30 días del vencimiento del plazo de 90 días, es
decir, dentro de 120 días a partir de la fecha en que presentó su queja con el destinatario. Si éste le entrega un Aviso de Acción Definitiva por escrito
con respecto a su queja y usted sigue inconforme con la decisión o resolución, puede presentar una queja con el CRC. Hay que presentarla dentro de
los 30 días subsiguientes a la fecha en que recibió el Aviso de Acción Definitiva.
INSTRUCCIONES DETALLADAS PARA CLASIFICAR UNA QUEJA
D WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) / TRADE ADJUSTMENT ASSISTANCE (TAA) y TRADE READJUSTMENT
ALLOW ANCES (TRA):
Si cree haber sufrido discriminación en un programa o actividad con apoyo financiero a tenor del Titulo I de la WIOA o TAA/TRA, puede presentar una
queja dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de
asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el Director, Civil Rights Center (CRC), U.S. Dept. of Labor,
200 Constitution Avenue NW, Room N-4123, Washington, DC 20210. Si presenta su queja con el destinatario de asistencia federal o su contratista,
tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las dos fechas)
antes de presentar su queja al CRC. Sí el destinatario de asistencia federal no le entrega un Aviso de Acción Definitiva por escrito dentro de los 90
días de la fecha de presentación de su queja, usted puede presentar una queja con el CRC. La queja CRC debe presentarse dentro de los 30 días del
vencimiento del plazo de 90 días, es decir, dentro de 120 días a partir de la fecha en que presentó su queja con el destinatario. Si éste le entrega un
Aviso de Acción Definitiva por escrito con respecto a su queja y usted sigue inconforme con la decisión o resolución, puede presentar una queja con el
CRC. Hay que presentarla con el CRC dentro de los 30 días subsiguientes a la fecha en que recibió el Aviso de Acción Definitiva.
D TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) / CHOICES and/or CHILD CARE SERVICES (CC):
Si cree haber sufrido discriminación en un programa o actividad a tenor TANF/Choices y/o Child Care Services (CC) que recibe asistencia financiera
federal, puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de
Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con la Office for Civil Rights,
1301 Young Street, Suite 1169, Dallas, TX 75202, (800) 368-1019. Si cree haber sufrido discriminación en un programa o actividad a tenor de la CC
que recibe asistencia financiera federal de USDA, puede proponerse en contacto con el U.S. Department of Agriculture (USDA), Office of Adjudication,
1400 Independence Avenue, SW, Washington, D.C. 20250-9410. Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a
que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las dos fechas) antes de presentar su
queja al U.S. Dept. of Health and Human Services.
D SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM EMPLOYMENT AND TRAINING (SNAP E&T):
Si cree haber sufrido discriminación en un programa o actividad con apoyo financiero a tenor del programa SNAP E&T, puede presentar una queja,
dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia
federal (o la persona designada por el destinatario para ese efecto), o bien, con el U.S. Department of Agriculture, Director, Office of Adjudication, 1400
Independence Avenue, SW, Washington, DC 20250-9410 o llame al 202-260-1026. Si presenta su queja con el destinatario de asistencia federal o su
contratista, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las
dos fechas) antes de presentar su queja al U.S. Dept. of Agriculture.
Favor de no firmar sin haber leído este aviso y haber comprendido su contenido.
Por mi firma abajo, reconozco esta orientación al procedimiento de queja de la discriminación y la declaración con respecto a que la igualdad de
oportunidades es la ley. Afirmo que he leído el Formulario para la Orientación a los Procedimientos de Queja de Discriminación y que me han dado la
oportunidad de hacer preguntas acerca de su contenido. Entiendo que el formulario One-Stop no es solicitud para trabajo; se utiliza para determinar mi
elegibilidad para recibir servicios de programa y para cumplir con requisitos federales de información. Entiendo también que la falta de proporcionar la
información pedida puede evitar que reciba servicios.
Firma del solicitante
Nombre en letra de molde
Fecha
EMPLEADOR
CON IGUALDAD
DE OPORTUNIDAD
EMPLEO/PROGRAMAS
Auxiliary aids and services are available upon request
to individuals
with disabilities.
Relay DE
Texas:
1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
Ayudas auxiliares y servicios están disponibles a petición para individuos con incapacidades
Relay Texas: 1-800-735-2989 (TTY); 1-800-735-2988 (Voz); 1-800-622-4954 (Español)
August2015
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LOWER RIO GRANDE VALLEY WORKFORCE DEVELOPMENT BOARD
ORIENTATION TO DISCRIMINATION COMPLAINT PROCEDURES FORM
(29 CFR Part 38)
This Orientation to Discrimination Complaint Procedures Form addresses discrimination complaint procedures for the listed programs
and services administered in the local workforce development area by the Workforce Development Board and its Contractors:
Workforce Innovation and Opportunity Act (WIOA) Temporary
Assistance for Needy Families (TANF) / CHOICES
Supplemental Nutrition Assistance Program Employment & Training (SNAP E&T)
Child Care Services (CC)
Trade Adjustment Assistance (TAA) and Trade Readjustment Allowances (TRA)
THE RECIPIENT OF THE FEDERAL FINANCIAL ASSISTANCE IS:
LRGV Workforce Development Board
3101 West Business 83
McAllen, TX 78501
Equal Opportunity (EO) Officer: Robert Barbosa
Telephone Number: (956) 928-5000
Relay Texas: 1-800-735-2989/ TTY 1-800-735-2988 (Voice)
The LRGV Workforce Development Board (the Board) shall resolve equal opportunity complaints in a fair and prompt manner. Acts of restraint, interference,
coercion, discrimination, or reprisal towards complainants exercising their rights to file a complaint under this procedure are prohibited. This procedure applies to all
applicants and participants who have cause to file a discrimination complaint related to activities or programs administered by the Board. If you have an equal
opportunity complaint concerning any of these programs, you may submit your written complaint to the Board or Contractor EO Officer, as appropriate.
After your equal opportunity complaint has been received, the EO Officer will notify you of the next step in the complaint process. As long as you wish to pursue your
complaint, the Board or Contractor will follow the steps described below. You should study the Discrimination Complaint Procedure carefully, and if you feel that
the required steps are not being followed, contact the EO Officer. Remember, if you feel you are not being provided enough help at any stage of the complaint
process, you should contact:
Texas Workforce Commission (TWC)
Equal Opportunity Monitoring
101 E. 15th St., Room 242-T
Austin, TX 78778-0001
Telephone Numbers:
(512) 463-2400
Relay Texas: 1-800-735-2989
TTY 1-800-735-2988 (Voice)
EQUAL OPPORTUNITY IS THE LAW
It is against the law for this recipient of Federal financial assistance to discriminate on the following bases: against any individual in the United States, on the basis of
race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of programs financially assisted under Title I of the
Workforce Innovation and Opportunity Act (WIOA), on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the
United States, or his or her participation in any WIOA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following
areas: deciding who will be admitted, or have access, to any WIOA Title I-financially assisted program or activity; providing opportunities in, or treating any person
with regard to, such a program or activity; or making employment decisions in the administration of, or in connection with, such a program or activity.
What to do if you believe you have experienced discrimination. If you think that you have been subjected to discrimination under a WIOA Title I-financially
assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: the recipient’s Equal Opportunity Officer (or
the person whom the recipient has designated for this purpose); or the Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue
NW, Room N-4123, Washington, DC 20210. If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final
Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a
written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing
a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which
you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the
decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final
Action.
PROCEDURES ON HOW TO FILE A COMPLAINT
D WORKFORCE INVESTMENT ACT (WIA) / TRADE ADJUSTMENT ASSISTANCE (TAA) and TRADE READJUSTMENT ALLOW ANCES (TRA):
If you think you have been subjected to equal opportunity discrimination under a WIA Title I or a TAA/TRA financially assisted program or activity, you
may file a discrimination complaint within 180 days from the date of the alleged violation with either the Board/Contractor Equal Opportunity Officer (or
designee) or Director, Civil Rights Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N-4123 Washington, DC 20210. If you file
your complaint with the Board or Contractor, you must wait until you receive a written Notice of Final Action or 90 days have passed (whichever is
sooner) before you can file with the CRC. If the written Notice of Final Action is not issued within 90 days of the day you filed your complaint, you have
30 days following the 90-day deadline to file a complaint with CRC (that is, within 120 days of the day you first filed your complaint). If you receive a
written Notice of Final Action on your complaint but are dissatisfied with the decision, you may file a complaint with CRC. However, you must file your
CRC complaint within 30 days of receiving the Notice of Final Action.
D TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) / CHOICES and/or CHILD CARE SERVICES (CC):
If you think you have been subjected to equal opportunity discrimination under a TANF/Choices and/or Child Care Services (CC) financially assisted
program or activity, you may file a complaint within 180 days from the date of the alleged violation with either the Board/Contractor Equal Opportunity
Officer (or designee) or the Office of Civil Rights, U.S Department of Health and Human Services (HHS), 1301 Young Street, Suite 1169, Dallas, TX
75202, (214) 767-4056. Those filing complaints on child care services may choose to contact the U.S. Department of Agriculture (USDA), Office of Civil
Rights-Southwest Region, Food and Nutrition Services, 1100 Commerce Street, Room 555, Dallas, Texas 75242, (214) 290-9837.
If you file your
complaint with the Board or Contractor, you must wait until a written Notice of Final Action is issued or until 90 days have passed (whichever is sooner)
before you can file with the U.S. Department of Health and Human Services.
D SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM EMPLOYMENT AND TRAINING (SNAP E&T):
If you think you have been subjected to discrimination under a SNAP E&T financially assisted program or activity, you may file a complaint within 180 days from the
date of the alleged violation with either the Board/Contractor Equal Opportunity Officer (or designee) or the U.S. Department of
Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC 20250-9410, (202) 260-1026. If you file your complaint
with the Board or Contractor, you must wait either until a written Notice of Final Action is issued or until 90 days have passed (whichever is sooner) before filing with
the U.S. Department of Agriculture.
Please do not sign this notice until you have read it and understand its contents.
By my signature below, I acknowledge this orientation to the discrimination complaint procedure and the statement regarding Equal Opportunity Is the
Law. I affirm that I have read the Orientation to Discrimination Complaint Procedure Form and that I have been given the opportunity to ask questions
about its contents. I understand that the One-Stop application form is not a job application; rather, it is used to determine my eligibility to receive
program services and to meet federal reporting requirements. I further understand that failure to provide the requested information may prevent me
from receiving services.
Applicant Signature
Printed Name
Date
ANtoEQUAL
OPPORTUNITY
EMPLOYER
/ PROGRAM
Auxiliary aids and services are available upon request
individuals
with disabilities.
Relay Texas:
1.800.735.2989 (TDD) and 1.800.735.2988 (Voice) or 711
R 6.29.15
Auxiliary aids and services are available upon request to individuals with disabilities
Relay Texas: 1-800-735-2989 (TTY); 1-800-735-2988 (Voice); 1-800-622-4954 (Español)
August 2015
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