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201 Appendix J. Child Care Subsidy Service Application and Redetermination Form Instructions NUMBER 032-25-0147-06-eng (07/22)

PURPOSE OF FORM To record all eligibility related information provided by an applicant for child care subsidy payments in the VaCMS. To be completed by the applicant at application and redetermination Form may be completed by the applicant in CommonHelp or submitted in writing to the LDSS. Information must be recorded in the VaCMS.

USE OF FORM To provide a record of new applications, redeterminations, the beginning of a transitional case and changes reported by an applicant that would affect their eligibility for child care subsidy in the VaCMS. For reported changes, the worker must record the change(s) in the VaCMS. The revised information will be stored in the VaCMS.

The form is available on the Child Care and Development website and the VDSS public website. Printed copies may be distributed at the LDSS, or the form can be printed from the VDSS public website by the applicant. Applicants may also apply online through CommonHelp.

COPIES The information will be stored in the VaCMS. The Responsibilities, Change Reporting, and Penalties section and the signature page of the form, signed by the applicant and the worker, must be given to the applicant. The signed application must be scanned into DMIS for the case record.

INSTRUCTIONS FOR PREPARING THE FORM This form is to be completed by an applicant for child care services. It is the responsibility of the worker to discuss all information with the applicant to ensure accuracy. It is the responsibility of the worker to evaluate all information provided by the applicant and to verify eligibility requirements. If the worker changes information completed by the applicant, both the worker and the applicant must initial the change and indicate the date the change was made.

General Information about the form:

Applicant’s Rights Outlines for applicants their responsibilities related to their application for child care subsidy or their continued eligibility for child care subsidy.

Outlines the steps an applicant for or recipient of child care services must take to appeal an agency decision.

Instructions for Completing the Application Outlines for applicants the instructions for completion of the application for child care subsidy.