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or US Coast Guard Certified, Tribally Approved or Tribally Certified, Nationally Accredited or Nationally Certified Day Camp or similar facility, includes the following forms and verification requirements that must be completed and submitted to the Designee:

1. Certified/Accredited Provider Child Care Assistance Application CC84;

2. State of Alaska Substitute Form W-9;

3. Child Care Provider Rates and Responsibilities CC12;

4. A copy of a current accreditation, approval, or certification from the US Department of Defense or US Coast Guard, tribal entity, or national accrediting or certifying agency. If the valid certification has not been issued for a US Department of Defense or US Coast Guard Certified provider, a copy of the facility’s letter issuedby either the US Department of Defense or a branch of military responsible for the oversight of the facility, identifying they are in compliance is acceptable;

5. A copy of the standards used in the accreditation, approval or certification of US Department of Defense, US Coast Guard, Tribally Approved, Tribally Certified, Nationally Accredited, or Nationally Certified Day Camp or similarfacility;

6. Verification of completion of the Child Care Assistance Licensed/ Certified Provider Orientation must also be received, and

7. The Electronic Payment Agreement for Vendors Doing Business with the State of Alaska form is strongly encouraged and provided to each applicant however is not required. If provided it is forwarded to the Child Care Program Office with the State of Alaska Substitute Form W-9 at the time of program approval.

The application forms must be signed by the owner or Administrator of the facility, as identified in ICCIS. If the business owner in ICCIS is a corporation, the individual signing the application and/or identified as having signing authority must be listed in the provider’s Staff/HH screen in ICCIS.

4200-2 C. APPROVED RELATIVE PROVIDERAPPLICATION SUBMISSION