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COPIES The original will be mailed to the recipient, and one copy must be scanned in the case record.

INSTRUCTIONS FOR PREPARING THE FORM The Child Care Worker in the transferring agency must complete the form and include the address and phone number of the agency to which the case is being transferred. Information will be preprinted on the form that is generated from VaCMS.

The last two pages of the form provide information on reporting changes, electronic correspondence, nondiscrimination, and the appeal/hearing process.

Appendix V. Vault ECC Card Issuance Authorization Form Instructions

FORM NUMBER 032-12-0137-00-eng (02/20)

PURPOSE OF FORM Child Care Worker will use this form to communicate with Issuance personnel in the local agency.

USE OF FORM The Child Care Worker must complete the top portion of the form to authorize the issuance of a vault card to the primary cardholder for their use, or for use by a secondary cardholder listed in VaCMS. Issuance personnel must complete the bottom portion of the form to document the action taken. The primary cardholder must also sign the form to acknowledge receipt of the vault card.

COPIES Issuance personnel must retain a copy of the fully completed form and return the second copy to the Child Care Worker. Upon receipt of the form, the Child Care Worker must file the copy in the case record.

INSTRUCTIONS FOR PREPARING THE FORM The Child Care Worker must complete the identifying case information and forward to Issuance personnel for completion. Issuance personnel must prepare a vault card, obtain and record identity verification, and secure the signature of the primary cardholder on the form before releasing the vault card. Issuance personnel must note if a vault card was not prepared. Issuance personnel must sign and date the form.

Appendix W. Vault ECC Card Inventory Control Record Form Instructions

FORM NUMBER 032-12-0138-00-eng (02/20)