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Appendix Y. Authorization to Act as Agent on Customer’s Behalf for In-Home Care

NUMBER 032-05-0061-03-eng (09/20)

PURPOSE OF FORM This form is used to obtain the permission of customers for the Virginia Department of Social Services to act as their fiscal agent when they use in home child care providers. The department can then withhold the proper federal and state work related taxes for the provider such as FICA, SUTA, and FUTA to satisfy all requirements of the Internal Revenue Service.

USE OF FORM Once this form is signed, the department can then withhold the necessary taxes on behalf of the in- home child care provider. The provider is not the employee of the department, but rather the employee of the customer.

COPIES The original is mailed to the Child Care Subsidy Provider Coordinator in Home Office. Copies will be given to the customer and the provider, and one copy will be saved in the VaCMS.

INSTRUCTIONS FOR PREPARING THE FORM Fill in the name, address, phone number, and case number of the customer and the name, address and phone number of the LDSS. The customer signs and dates the form after explanation by the Child Care Worker.

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Page 203

Official source

203

Appendix Y. Authorization to Act as Agent on Customer’s Behalf for In-Home Care

NUMBER 032-05-0061-03-eng (09/20)

PURPOSE OF FORM This form is used to obtain the permission of customers for the Virginia Department of Social Services to act as their fiscal agent when they use in home child care providers. The department can then withhold the proper federal and state work related taxes for the provider such as FICA, SUTA, and FUTA to satisfy all requirements of the Internal Revenue Service.

USE OF FORM Once this form is signed, the department can then withhold the necessary taxes on behalf of the in- home child care provider. The provider is not the employee of the department, but rather the employee of the customer.

COPIES The original is mailed to the Child Care Subsidy Provider Coordinator in Home Office. Copies will be given to the customer and the provider, and one copy will be saved in the VaCMS.

INSTRUCTIONS FOR PREPARING THE FORM Fill in the name, address, phone number, and case number of the customer and the name, address and phone number of the LDSS. The customer signs and dates the form after explanation by the Child Care Worker.