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Appendix I. Forms Used in the Child Care Subsidy Program

The forms utilized in the Child Care Subsidy Program are identified below. Forms can be accessed through FUSION at: CCECD Forms or at https://fusion.dss.virginia.gov/home/fusion-forms-library.

FORM NAME FORM NUMBER Appeal to State Department of Social Services 032-03-0024-10-eng (01/10) Authorization to Act as Agent on Customer’s Behalf for In-Home Care 032-05-0061-03-eng (09/20) Child Care Case Record Transfer Form 032-25-0148-00-eng (07/18) Child Care Subsidy Program Communication Form 032-05-0518-02-eng (07/18) Child Care Subsidy Program Notice of Action 032-12-0128-01-eng (07/18) Child Care Notice of Case Transfer Form 032-25-0149-00-eng (07/18) Child Care Notice of Redetermination 032-12-0131-00-eng (08/17) Child Care Purchase of Services Order (POSO) 032-05-0540-02-eng Child Care Repayment Agreement 032-12-0130-00-eng (08/17) Child Care Subsidy Program Service Plan 032-12-0129-02-eng (06/22) Child Care Subsidy Service Application and Redetermination Form 032-25-0147-06-eng (07/22) Child Care Subsidy Service Application and Redetermination Form 032-25-0147-06-spa (07/22) Child Care Provider Demographics 032-05-0548-01-eng (10/16) Child Care Verification Checklist 032-12-0127-00-eng (03/17) Child Care Waitlist Screening Form 032-05-0547-03-eng (03/21) Child Care Waitlist Update Form 032-12-0132-00-eng (08/17) Child’s Emergency Medical Authorization 032-02-057/2 (10/02) Childhood Immunization Certification TANF and Child Care Subsidy 032-03-0960-03-eng (11/03) Health and Safety Checklist for Unregulated Providers 032-02-001/2 (10/02) Sworn Statement or Affirmation for Child Day Programs 032-05-0160-10-eng (05/17) Va-ECC Provider Attendance Report (form for manual attendance) 032-05-0546-B0-eng (8/19) Subsidy Provider Attestation Form 032-035-0095-eng (06/25)

Forms Used in IPV Process FORM NAME FORM NUMBER Administrative Disqualification Hearing Decision 032-03-0723-10-eng (05/16) Advance Notice of Administrative Disqualification Hearing 032-03-0724-08-eng (05/16) Notice of Disqualification for Intentional Program Violation 032-03-0052-13-eng (05/16) Notice of Intentional Program Violation 032-03-0721-11-eng (04/16) Referral for Administrative Disqualification Hearing 032-03-0725-05-eng (05/16) Waiver of Administrative Disqualification Hearing 032-03-0722-03-eng (05/16)

Forms Used in OTC Process FORM NAME FORM NUMBER Monthly Vault ECC Card Used Report 032-12-0139-00-eng (02/20) Vault ECC Card Inventory Control Record 032-12-0138-00-eng (02/20) Vault ECC Card Issuance Authorization Provider Agreements 032-12-0137-00-eng (02/20)

The forms used for providers interested in becoming an approved provider of subsidized child care can be accessed at: www.childcare.virginia.gov