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~ C) /'\_ "1 I I I I I I I I I I I I I I I I CC-214 (1-14) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Child Care Administration CHILD CARE PROVIDER RATE AGREEMENT Please read the reverse for additional information. PROVIDER/FACILITY'S NAME PROVIDER NUMBER Check () only one INITIAL RATE NOTIFICATION RATE REVISION Instructions to Child Care Provider: 1. Complete and submit original and canary copy of this agreement (faxed copies are unacceptable). 2. Rate revision only: (ALL RATE REVISIONS SHALL BE EFFECTIVE ON THE FIRST DAY OF THE MONTH.) Provider shall submit the Child Care Provider Rate Agreement a minimum of 30 days prior to the proposed effective date of any changes to the Child Care Provider’s rates. Enter the month and year your proposed rate revision will begin (Month and year entered may not be the same month and year DES makes rates effective.) F O R DES USE ONLY 3. Rates entered in the “PROVIDER’S RATE” column below must be your normal and customary charges. R ates entered to this column will a pply to all families (DES and non-DES families) enrolled in the provider’s facility. Information Regarding the DES Reimbursement Rates: 1. The DES will pay the rates indicated in the shaded area entitled RATES AUTHORIZED BY DES minus any DES required customer co-payment. (Co-payment: An amount established by DES requiring families to pay to the provider.) 2. The DES shall review its provider’s rates, complete the shaded areas, sign the Agreement and return the canary copy to the provider. DES shall maintain the original in the provider’s file. 3. Reimbursement rates authorized by DES under this Agreement may be revised through a fully executed Child Care Provider Rate Agreement or upon thirty (30) days written notice to the provider of the revised reimbursement rates established by DES. DO NOT LIST HOURLY, WEEKLY, OR MONTHLY RATES. RATES ENTERED B ~ EA LOW SHOULD BE A FULL DAY DAILY RATE AND/OR A PART DAY DAILY RATE. C D D E S

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O N L Y Distribution: Original, white, to DES Provider File • Copy, canary, to Provider See reverse EOE/ADA/LEP/GINA disclosures. CC-214 (1-14) – Page 40 Arizona Department of Economic Security