ࡱ> ILFGHO fbbjbj ~fefeXk k k !l;# t*W&'''',,,hsjsjsjsjsjsjs$=wy*sk 4+,44s''s4:::4l'k 'hs:4hs::.xgH? ,l'4 /5i@Tss<tj|5|ll|k lx,D/:0L2,,,ssO8D,,,t4444|,,,,,,,,, : Confidential Application for Child Development Services and Certification of Eligibility Form ELCD 9600, Page 1, (REV. 12/17)  Note: State regulations require a formal application and certification for child development services. You will receive written notice of your eligibility no later than 30 days from the date of your signature on this form. This form must be completed by an agency representative in consultation with the family. The agency must verify and certify family eligibility prior to beginning services. Refer to the attached instructions for the completion of this form. Section I. Family Identification. If you are a single parent/caretaker, check this box: See Instructions, Section I.Name of parent/caretaker (full name, including middle initial) A.Phone no. (cell or home)Phone no. (work/school)Name of parent/caretaker (full name, including middle initial) B.Phone no. (cell or home)Phone no. (work/school)Street address CityStateZipFIPS codeSection II. Family Eligibility and Reason for Needing ServiceA. Family Eligibility Status (Check as many as apply.) Protective ServicesCurrent Aid RecipientIncome Eligible  Homeless Programs for the Severely HandicappedCSPP Only-Qualified FRPM ResidentB. Reason for Needing Service. Indicate all the reasons for needing care for each adult listed above. Enter A or B referring to parent/caretaker listed above. Attach documentation. (This section does not apply to part-day state preschool programs or programs for severely handicapped.) Parent/ CaretakerReason for Needing ServiceParent/ CaretakerReason for Needing ServiceParent/ CaretakerStages 1, 2, and 3 CalWORKs recipients onlyHomelessEducation or trainingCalWORKs activitiesDate parent became ineligible for aid: Date: ____________WorkingActively seeking employmentDiversionChild referred for protective services because of neglect, abuse, exploitation, or At-Risk thereofSeeking permanent housingRecord date of entry into each stage: Stage 1:_______ Stage 2:_______ Stage 3:________Parent/caretaker incapacitated because of medical or psychiatric special needsCSPP Only - No Need RequiredCSPP Only - FRPM Qualified ResidentC. Employment/Training Information. Must be completed for each adult listed in Section I above to document need on the basis of employment or training. (Attach documentation.) Parent/ Caretaker Employer/School Street AddressCityZip A     A     Days and working/ training hours: From: To: Mon. Tues. Wed. Thurs. Fri. Sat. Sun. Parent/ Caretaker Employer/School  Street Address City Zip B     B     Days and working/ training hours: From: To: Mon. Tues. Wed. Thurs. Fri. Sat. Sun. Section III. Family Adjusted Gross Monthly Income and Size A. Family monthly income. The family's adjusted monthly income from all sources (Attach verification and documentation.): $___________________________ B. Family income sources (Check all that apply. Do not count the gray shaded areas in Section III. A above.) Black shaded boxes for CalWORKs recipients only. NOTE: Section III B is for federal data collection purposes only. Employment, including self-employmentOther federal cash income programs (such as SSI)Child supportHousing voucher or cash assistanceCash or other assistance under Title IV of the Social Security Act (TANF)Assistance under the Food Stamps Act of 1977 State-only alien and two-parent programs for CalWORKs recipientsOther: C. Family size (See Funding Terms and Conditions for instructions on calculating family size.): _________________ D. Parent(s) currently on active duty (i.e. serving full-time) in the U.S. Military? YES ___ NO ___ E. Parent(s) a current member of a National Guard or Military Reserve Unit? YES ___ NO ___ Confidential Application for Child Development Services and Certification of Eligibility Form ELCD 9600 Page 2, (REV. 12/17) Section IV. Data on Children. List ALL children residing in the home and counted in the family size. Complete for all children residing in the homeComplete only for children served by your agencyFor children enrolled in more than one program or site, use additional lines as needed (1) Full Name of Child Including Middle Initial (2) Gender (3) Birth Date (4) Adjustment Factor Code (5) (6) (7) Native Language (8) Program Code (9) Type of Care Code (10) Hours of Care per Day M FMM/DD/YYYYEthnicityRace  Language CodeChild is English Learner? (School age ONLY)  M T W T F S S         S       Provider/site name:V          S     Provider/site name: V          S Provider/site name:V           S     Provider/site name: V     Section V. Certification and Signature of Parent/Caretaker.I understand that I am self-certifying single parent status under penalty of perjury in Section 1 of this document when the single parent/caretaker box has been checked. Parent Initials: ____________ I understand that the information about my eligibility may be reviewed by representatives of the State of California, the federal government, independent auditors, or others as necessary for the administration of the program. I understand that if the agency denies this application for services, I have the right to appeal. I understand that I will receive a notice of approval or disapproval of my application within 30 days from the date I sign this form. I understand that this certification is not complete until all documentation is submitted and this form has been signed and dated by me and reviewed, signed, and dated by an agency representative. I certify that my family assets do not exceed $1,000,000; Child Care and Development Block Grant Act Section 658 p (4)(B). I understand that I must renew my eligibility at least once a year. I further understand that if I do not renew my eligibility, I will no longer be eligible for subsidized child care services for my child. I DECLARE UNER PENALTY OF PERJURY THAT THE ABOVE INFORMAITON IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.Signature Date Relationship to Child:  FORMCHECKBOX Parent  FORMCHECKBOX  Grandparent  FORMCHECKBOX  Guardian  FORMCHECKBOX  Foster Parent  FORMCHECKBOX  Other: Please describe _________________Signature Date Relationship to Child:  FORMCHECKBOX Parent  FORMCHECKBOX  Grandparent  FORMCHECKBOX  Guardian  FORMCHECKBOX  Foster Parent  FORMCHECKBOX  Other: Please describe _________________Section VI. Family Fee (Refer to the current CDE Family Fee Schedule).Type of FeeFlat Monthly Fee Rate (See the instructions for Section VI.) FORMCHECKBOX  Full-time 130 hours or more per month Flat Monthly Rate: Specifics:  FORMCHECKBOX  Part-time Under 130 hours per monthFlat Monthly Rate: Specifics: Section VII. For Office Use Only. (Certification is not complete until eligibility is reviewed, signed, and dated by an agency representative.)Eligibility Status:  FORMCHECKBOX  Denied  FORMCHECKBOX  Approved Site Name: ___________________________________ Date Notice of Action Sent (Attach copy)Date Notice of Action Given (Attach copy)First date of subsidized serviceLast date of enrollmentSignature of Authorized Agency Representative Title Telephone numberDateSignature of Supervisor (Optional) TitleTelephone numberDate Instructions for Completing Form ELCD 9600: Confidential Application for Child Development Services and Certification of Eligibility Form ELCD 9600 (or documentation containing the same information) must be completed and signed by the parent and an agency representative before the child enters the child development program. All certification forms and documentation must be maintained in the family file. Agency Name: Insert the name of the agency providing or funding child care services in this space. Check the FRPM Site box if the family is a CSPP site/classroom that is located within the attendance boundaries of a qualified FRPM School. Family Identification Number or Family Case Number: A Family Identification Number (FIN) or Family Case Number (FCN) must be assigned to each family. Enter the unique FIN in top box on page one of the form ELCD 9600. Initial Subsidized Service Date: This is the earliest month and year that the child(ren), as listed on this ELCD 9600, first started receiving subsidized child care services from your agency. Every ELCD 9600 must have a month and year entered in this field. This information is for data reporting purposes. If there is a break of three months or more, enter the month child care resumed. If there is a break of less than three months (vacation, for example), enter the original date assistance began, not the date it resumed. Type of Application: Check the box after "Initial" if this is the first application taken by the agency named on this ELCD 9600. Check the box after "Recertification" if this is the second or later application taken by the agency listed on this ELCD 9600. Section I. Family Identification Note: If family size includes more than two adults, complete Sections I, II, and III of a second ELCD 9600 and attach it to the complete ELCD 9600. You may also use a second ELCD 9600 to record additional employers or training institutions for the parents listed under A and B in Section I. Single parent/caretaker: If the child lives with only one parent/caretaker who is legally/financially responsible for the child, check the box on the line next to Section I. Family Identification Information on parent/caretaker A. For the first adult living in the same household as the child(ren), complete all items in Section I, including address information. For the purposes of these instructions and the certification of eligibility, a parent/caretaker shall be a person who has responsibility for the child. Thus, parent/caretaker could refer, for example, to a biological parent, a stepparent, a grandparent, a foster or adoptive parent, or a legal guardian. FIPS Code. See the FIPS Codes section on page three of these instructions to determine the FIPS Code that identifies the state and county where the parent/caretaker lives. Information on parent/caretaker B. If a second parent/caretaker lives in the same household as the child and is included in the calculation of family size, complete all items in Section I B. Section II. Family Eligibility and Reason for Needing Service NOTE: For part-day services, family eligibility is determined based on adjusted gross monthly income in relation to family size only. For full-day services, family eligibility is determined based on adjusted gross monthly income in relation to family size and the familys need for child development services and/or CalWORKs status. Family eligibility status. Check all eligibility categories for which the family qualifies. B. Reason for needing service. For each parent/caretaker or other adult included in the family size, note with an A or B all of the reasons for needing services and attach the appropriate documentation. Identify the main reason for needing service with an asterisk if there is more than one reason. Do not complete this section for part-day state preschool or severally handicapped. CalWORKs recipients only: This box is to be completed for all CalWORKs recipients receiving services in Stages I, 2, or 3. If a parent/caretaker is completing CalWORKs activities, enter A and/or B in the box labeled CalWORKs Activities." If a parent/caretaker has received a diversion payment, enter A and/or B in the box labeled Diversion. In the box labeled Record date of entry into each stage, enter the initial date of entry into each stage. For Stage I or II families no longer eligible for CalWORKs aid, enter the date the parent became ineligible for aid in the box labeled Date parent became ineligible for aid. C. Employment/training information. For each parent/caretaker, enter the name and address of the employer or the institution of training or education, as appropriate. Do not complete this section for part-day state preschool or programs for severally handicapped. Days and working/training hours. Note the beginning and ending hours for each day that the parent is employed or in a training program. Section III. Family Adjusted Gross Monthly Income and Size A. Family monthly income. Enter the familys total adjusted gross monthly income from all sources. All income must be verified. B. Family income sources. Check each box to identify all sources of family income. These include sources of income that are not counted for eligibility determinations. The black shaded boxes are to be completed for CalWORKs recipients only. County welfare departments will identify whether a CalWORKs recipient is receiving CalWORKs benefits under the State-only alien program or the state-only two-parent program. These two programs count toward Temporary Assistance to Needy Families Maintenance of Effort. The gray shaded boxes are not to be counted in the familys total adjusted monthly income. Instructions for Completing Form ELCD 9600: Confidential Application for Child Development Services and Certification of Eligibility (Continued) Section III. A Family Adjusted Gross Monthly Income and Size Section III. B is for federal data collection purposes only. Family Size. Enter the total family size, including (1) all parent(s)/caretaker(s) listed on the ELCD 9600; (2) all children named in Section V; (3) any adult listed on an additional ELCD 9600; and (4) any children listed on a second ELCD 9600. Family Military Status. Enter Yes if the parent(s) is currently serving active duty (i.e. serving full-time) in the U.S. Military. Enter No if the parent(s) is not on active duty. National Guard/Military Reserve Status. Enter Yes if the parent(s) is currently a member of either a National Guard unit or a Military Reserve unit. Enter No if the parent(s) is not a member of the National Guard or Military Reserve unit. Section IV. Data on Children Note: Complete columns 1 and 3 of this section for all children eighteen and under residing in the household. If needed, use a second ELCD 9600 to record more children. (1) Name of child. List all children included in the household size eighteen and under, for whom the parent(s) is responsible. NOTE: When a child and his or her siblings are living in a household that does not include their biological, or adoptive parent(s), family shall be considered the child and related siblings. List only the children of this family who are eighteen and under. (2) Gender. Check the appropriate box in column 2 for each child receiving care through this certification. (3) Birth date. In column 3 enter the birth dates of all children listed in column 1 following this format: month/day/year. (4) Adjustment factor code. See the Adjustment Factor Codes section in these instructions to determine the adjustment factor code that should be entered in column 4. If no adjustment factor is used, leave this box blank. (5) Ethnicity. Enter a Y if the child is Hispanic or Latino. Otherwise, enter an N. (6) Race: See the Race Codes section in these instructions to determine the race code(s) that should be entered in column 6. At least one code must be entered, but you may enter all codes that apply for each child. (7) Native language: See the Native Language Codes section in these instructions to determine the native language code that should be entered in column 7. Language Code. Use only those native language codes provided. Child is English Learner? For kindergarten through grade twelve children ONLY. For students reported with a primary language other than English, report the primary language of students on the state-approved Home Language Survey. (8) Program code. See the Program Codes section in these instructions to determine the program code(s) that should be entered in column 8. Enter one code per line for each child receiving child care services through this certification. If the child(ren) is enrolled in more than one program or with more than one provider, use additional lines to record this information in columns 8 and 9 for each child. (9) Type of care and relationship to child. See the Type of Care Codes section in these instructions to determine the type of care code(s) that should be entered in column 9. Enter the provider or site name in the space provided. (10) Hours of care per day. Enter the amount of child development services needed each day in column 9. Use the upper line (marked S) to indicate the amount of care needed during the school session; use the lower line (marked V) to indicate the amount of time needed during vacations. For preschool-age children, use only the upper line to record the amount of care needed. Section V. Certification and Signature of Parent/Caretaker Read and explain the conditions of eligibility and need to the parent/caretaker and make sure he or she understands them before signing the application. Parents must initial item 1 of Section V, if self-certifying by checking the box in Section I. Before the agency representative signs the form, the parent/caretaker completing the application must sign and date the form and indicate his or her relationship to the child. At least one parent signature is required on the application. Section VI. Family Fee Monthly Flat Rate: Use the most current effective Family Fee Schedule issued by the Early Learning and Care Division. Assess the Family Fee according to the family size, total countable income, and total monthly certified hours of care for the child(ren). If the family has more than one child receiving services, determine the family fee based on the certified hours of care for the child with the largest monthly number of approved certified hours. Full-time Fee: Assess a Full-time fee for certified need of 130 hours or more per month. Part-time Fee: Assess a Part-time fee for certified need of less than 130 hours per month. If applicable, the field labeled specifics should be used to explain determination of fee. Section VII. For Office Use Only The agency representative must complete the items in this section. The certification is not complete until it is signed and dated by the agency representative. The Signature of Supervisor is an optional field and is not required. Completing the Form Follow these procedures once you have completed the familys certification: A. File the completed form in the family file. B. If the family has a new or updated certification, add it to the family file. Do not remove the earlier applications. Instructions for Completing Form ELCD 9600: Confidential Application for Child Development Services and Certification of Eligibility Section I. Family Identification Federal Information Processing Standards (FIPS) Codes The FIPS code consists of a state code, which is a two-digit number, and a county code, which is a three-digit number. The codes are California - 06, Arizona - 04, Nevada - 32 and Oregon - 41. California County Codes are as follows: 001 Alameda 041 Marin 081 San Mateo 003 Alpine 043 Mariposa 083 Santa Barbara 005 Amador 045 Mendocino 085 Santa Clara 007 Butte 047 Merced 087 Santa Cruz 009 Calaveras 049 Modoc 089 Shasta 011 Colusa 051 Mono 091 Sierra 013 Contra Costa 053 Monterey 093 Siskiyou 015 Del Norte 055 Napa 095 Solano 017 El Dorado 057 Nevada 097 Sonoma 019 Fresno 059 Orange 099 Stanislaus 021 Glenn 061 Placer 101 Sutter 023 Humboldt 063 Plumas 103 Tehama 025 Imperial 065 Riverside 105 Trinity 027 Inyo 067 Sacramento 107 Tulare 029 Kern 069 San Benito 109 Tuolumne 031 Kings 071 San Bernardino 111 Ventura 033 Lake 073 San Diego 113 Yolo 035 Lassen 075 San Francisco 115 Yuba 037 Los Angeles 077 San Joaquin 039 Madera 079 San Luis Obispo If the family resides outside California, list the state code only. Section IV. Data on Children Column 4: Adjustment Factor Codes 21 Infant 24 Severely disabled 22 Exceptional needs 25 Limited English proficient (LEP) 23 Child protective services 27 Toddler Column 6: Race Codes 1 American Indian or Alaskan Native 2 Asian 3 Black or African American 4 Native Hawaiian or other 5 Caucasian Pacific Islander Column 7: Native Language Codes 11 Arabic 24 Hungarian 06 Portuguese 12 Armenian 25 Ilocano 28 Punjabi 42 Assyrian 26 Indonesian 29 Russian 13 Burmese 27 Italian 45 Rumanian 03 Cantonese 08 Japanese 30 Samoan 36 Cebuano 09 Khmer 31 Serbian (Visayan) (Cambodian) 52 Serbo-Croatian 54 Chaldean 50 Khmu 01 Spanish 20 Chamarro 04 Korean 46 Taiwanese (Guamanian) 51 Kurdish 32 Thai Column 7 Native Language Codes (Continued) 39 Chaozhou 47 Lahu 53 Toishanese 14 Croatian 07 Mandarin 33 Turkish 15 Dutch (Putonghua) 38 Ukrainian 00 English 48 Marshallese 35 Urdu 16 Farsi (Persian) 44 Mien 02 Vietnamese 17 French 49 Mixteco 55 Other 18 German 88 Native American Languages 19 Greek Languages of China 43 Gujarati 40 Pashto 66 Other 21 Hebrew 05 Pilipino Languages of 22 Hindi (Tagalog) the Philippines 23 Hmong 41 Polish 99 Other non- English Column 8: Program Codes (Contract Prefix) For current contract program codes and contract prefixes, access the Child Care and Development Contract Program Types Web page at  HYPERLINK "http://www.cde.ca.gov/sp/cd/ci/ccdprogramtypes.asp" http://www.cde.ca.gov/sp/cd/ci/ccdprogramtypes.asp. 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Charles Vail Charles Vail                        Oh+'0d    , 8DLT\PEESD9600 Confidential Application - Child Development (CA Dept of Education)This application for child care services is intended for use by CDE-funded providers to determine if the client meets the eligibility and need requirements.Charles Vail Normal.dotmCharles Vail6Microsoft Office Word@ԭ@k@R6nE@z" : jK ՜.+,D՜.+,T hp  5$California Department of Education-wX MEESD9600 Confidential Application - Child Development (CA Dept of Education) Title 8@ _PID_HLINKSA<`3http://www.cde.ca.gov/sp/cd/ci/ccdprogramtypes.asp  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./012345789:;<=?@ABCDEJKNRoot Entry F4 M@Data Pd1Table|WordDocument ~SummaryInformation(6DocumentSummaryInformation8>MsoDataStore4 4 AWPOCIDSNUWS4A==24 4 Item  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q