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CAPS Policy Manual

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APPENDICES AND FORMS

Appendix Form Number Form Name Appendix A

CAPS Maximum Income Limits Chart Appendix B

Save Verification Process Appendix C

Maximum Reimbursement Rate Chart Appendix D

Family Fee Assessment Chart Appendix E

Record Keeping Procedures for CAPS Case Files Appendix F

Employment Verification Appendix G Form 1 OSAH Administrative Hearing Form 1 Appendix H Child Welfare Child Care Services Referral Form Child Welfare Child Care Services Referral Form Appendix I Form 58 Informal Provider Enrollment Appendix J Form 60 CAPS Child Care Application Appendix K

Authorized Representative Form Appendix L Form 62 Disposition and Parent Information Appendix M Form 64 Voluntary Withdrawal Form and Voluntary Withdrawal-During Eligibility Period Appendix N Form 66 Appointment Letter and Verification Checklist Appendix O Form 111 (C & P) Repayment Statement (Parent and Provider) Appendix P Form 112 Report of Claim Determination Worksheet Appendix Q Form 113 (C & P) Child Care Claims and Collection Notice ( Parent and Provider) Appendix R Form 114 (C & P) Hardship Repayment Request (Parent and Provider) Appendix S Form 600 CAPS Referral for Georgia's Pre-K Program Appendix T Form 633 Informal Provider Monitoring Checklist Appendix U Form 704 Civil Rights Compliance for Child Care Providers Appendix V Form 5667 & 5776B Request For Investigation (Parent and Provider) Appendix W Form W-9 IRS Taxpayer Identification Form Appendix X

Uniform Accounting System (UAS) Code Listing Appendix Y Form 601 Child Care Provider Agreement