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A copy must be sent to the recipient. This copy of the POSO is notification of how many units of care have been authorized, the effective date of the POSO, the family copayment amount and the copayment effective begin date.

A new POSO will be available to the provider in EPPIC with the revised information if child care services continue.

INSTRUCTIONS FOR PREPARING THE FORM:

All information is pre-filled by the system.

SIGNATURE OF FISCAL WORKER OR DIRECTOR DESIGNEE The POSO will be populated with the electronic signature of the Child Care Worker and the Locality Signing Officer listed on the LDSS Profile Screen in VaCMS. “The decision to delegate the fiscal signatory responsibilities to an employee other than the fiscal officer would be made by the LDSS Director. The Director would be responsible for ensuring the designee has the fiscal knowledge required to sign as the authorizing agent while maintaining the appropriate segregation of duties.” (Finance Guidelines Manual for LDSS Section 5.20 – Purchase of Service-Provider Process, Section 3, Purchase of Service Order, Page 5).

Appendix S. Child Care Repayment Agreement Form Instructions

FORM NUMBER 032-12-0130-00-eng (08/17)

PURPOSE OF FORM The purpose of this form is to inform applicants or recipients of child care subsidy and services of any improper payment for services and to capture the applicant/recipient’s agreement for repayment of any improper payment.

USE OF FORM The form is used to capture the agreed upon terms for repayment of any improper payment made for Child Care Services. This form is generated from the intranet and shall be printed by the worker and sent to the applicant/recipient. The correspondence ID # and the date the form was mailed must be recorded in the case narrative to verify the form was mailed to the applicant/recipient, if printed locally.

COPIES The original will be stored in the case record, and one copy must be given to the applicant/recipient. INSTRUCTIONS FOR PREPARING THE FORM – The Child Care Worker must indicate the service months included in the improper payment and the total amount of the improper payment that must be repaid.

The last page of the form provides information on the fair hearings and appeal process.