KNIK TRIBE CHILD CARE SUBSIDY APPLICATION
Dear Child Care Applicant:
Thank you for applying to the KTC Child Care Assistance Program. To be eligible for this program, you must:
____Currently be employed andworking at least 20 hours or more per week; or
____Enrolled in an accredited higher education program taking a minimum of 6 credits per semester.
(Child care assistance is not provided for study time).
____Enrolled in an accredited job-training program; or
____Enrolled in High School.
____BIA Certificate of Indian Blood or Tribal documentation, or proof of descent, for child(ren) needing care.
PLEASE SUBMIT YOUR COMPLETED Child Care ASSISTANCE Application,INCLUDING ALLof the required documentatiON.IN TWO PARENT/ADULT HOUSEHOLDS, documentation is required from BOTH PARENT/ adults. Incomplete applications are not accepted.
Your application will be reviewed for eligibility. Your Child Care Authorizationwill be mailed to the address provided, within 10 days. The Child Care Authorization will inform you and your provider of the amount of child care assistance you are authorized to receive.Please notice thatall of the required documentation must be provided for both adults/parents if it the child resides in a two-parent/adult households. Child care subsidies are authorized only while both are scheduled to be at work or in school/training. Self-employed parents/adults are required to complete, sign and submit a Self-Employment Verification Form, in addition to their completed and signed Child Care Subsidy Application.
There are several types of providers to choose from to provide care for your child/ren, they are: Center-Based Provider; Group Home Provider; Approved Relative Provider; Non-Relative In Home Provider; or In-Home Provider. If you have chosen a provider who has not previously provided child care through the State of Alaska’s or a Tribal Child Care Assistance program, they must first become an Approved Provider, through the State of Alaska. These applications are available through the Child Care Assistance Coordinator.
REMINDER: Parents/Guardians must submit a Child Care Assistance Renewal Application every three months. Renewals are due by the first of: January, April, July and October. Failure to submit your renewal application will cause a lapse in payments for child care services being made by Knik’s Child Care Assistance Program. Payment will not be made for child care services received after the Authorized period has ended.
Failure to comply with the program’s Policies and Proceduresmay result in the participants being placed on a probationary period, and/or becoming terminated or debarred from the Child Care Assistance Program. Alldecisions regardingprobationaryperiods orterminationsareatthediscretionof theChildCarestaff.
The KTC Child Care Assistance Program provides funding for low-income families living within the Mat-Su Borough service area. Office hours are Monday - Friday, 8:00 a.m. - 5:00 p.m.
Page 1 of 11
Checklist
Parent Portion
Certificate of Indian Blood (or Tribal Certificate of Enrollment, Tribal ID, which shows Indian blood).
Birth Certificates for children who need child care services.
Proof of last 30-days Household Income (paystubs, or similar proof of income). If you’ve had no income, an income verification form must be signed and submitted.
If recently employed, a signed Letter of Hire from your employer stating your date of hire, your wage, and work schedule must be provided, preferably on letterhead.
* Additional documentation is required for those who are self-employed.
Copy of Court Ordered Child Custody Agreement, or Notarized Custody Agreement
signed byboth parents, which includes physical address, if applicable.
If you are attending –
College — Class schedule and budget forecast must be submitted.
Job Training— Training location, start and end dates, and the training schedule must be submitted.
Provider Portion
All of the following documentation must be included with the completed and signed
Provider’s Portion of the application.
Copy of all of the Provider’s licenses, i.e.: Child Care Provider License, Business Licenses State, Borough (and City if applicable).
Proof of liability insurance.
Completed and signed w-9 form.
INCOME SOURCES
Check all sources of income that apply and provide us with copies. / Last 30 Days / Last 12 Months / Last 30 Days / Last 12 MonthsEmployment (must have check stubs showing gross wages with mandatory & voluntary deductions). / / / Child Support;or verbal agreementwith other parent (provide a signed statement). / /
Unemployment Benefits / / / Inheritance / /
Social Security Income (SSI) / / / Retirement Pension / /
General Assistance (GA) / / / Native Corp. Dividends / /
General Relief (GR) / / / ATAP/TANF / /
Child Care: CITC, DPA, or DCAP / / / Other (Please list): / /
Longevity Bonus / / / /
Support by others / / / /
Foster Care Payments / / / /
EMPLOYMENT or EDUCATION/TRAINING ACTIVITY
Applicant Information / Spouse InformationJob Title or Course of Study: / Job Title or Course of Study:
Employer or Education/Training Institute: / Employer or Education/Training Institute:
Address: / Address:
Contact Person: / Telephone: / Contact Person: / Telephone:
Start Date: / End Date: / Start Date: / End Date:
Specify Work Schedule: / Hourly Rate: / Specify Work Schedule: / Hourly Rate:
Education Plans(completion required for Scholarships)
College/School Attending & Address: / Financial Aid Office Phone and Building Number: / Financial Aid Fax Number:
Term Type: / Actual Term Start dates: / Number of Credits:
□ Quarter □ Tri/Semester □ Other / Fall: / Winter: / Spring:
Field of Study: / Expected Degree/Certificate:
Class Standing: / □ Freshman □ Sophomore □ Junior □ Senior □ Graduate □ Other
Selective Service registered? / □ Yes □ No / Expected Graduation/Completion Date:
Educational Goals(completion required for Scholarships)
Please State Your Educational Objective. If more space is needed, please attach a separate piece of paper.
Budget Information(completion required for Scholarships)
Expenses: Estimate your total monthly household expenses / Supplies: Please list all requested tools, clothing, or supplies, and acquire a quote from the vendor:
Type of Expense / Amount / List type of Supplies: / Cost of Supplies:
Food / $ / $
Heating Oil/Propane/Natural Gas / $ / $
Phone / $ / $
Electric / $ / $
Water / $ / $
Rent/House Payment / $ / $
Gasoline / $ / $
Cable Television / $ / $
Child Care / $ / $
Car Payment / $ / $
Insurance / $ / $
Other: / $ / $
Total Estimated Monthly Expenses / $ / Total Supply Cost
Attention: By signing below, I am indicating that I understand Knik Tribal Council requires me to utilize the funds in a responsible manner. I also understand that I must maintain a GPA of 2.0 or higher, and stay in good standing with the university or education facility, which I am attending. or supported work service. Refusal to cooperate fully with this policy may result in the denial of financial assistance through Knik Tribal Council for training and supported work service.
Member Signature / Date
HOUSEHOLD INFORMATION
Please list all persons beginning with yourselfwho live in your household (including spouses or boy/girl friends) and check DD box if individual is Developmentally Disabled or SN box if individual is Special Needs. If you need additional space, please use the back of this form. Developmentally Disabled - Must provide adequate documentation verifying that the family member has a developmental disability. Special Needs Child is a.) In Child Protective Services Care; b.) Receiving ICWA Services; c.) Homeless; d.) A child of a Teenage Parent.
Name / Relationship to Applicant / Highest Grade Completed / Male or Female / DOB / Age / Social Security # (do not leave blank)SELF
DD or SN
DD or SN
DD or SN
DD or SN
DD or SN
DD or SN
DD or SN
DD or SN
CHILD(REN) NEEDING ASSISTANCE
List all children living within your household for whom you are requesting child care assistance and have legal custody.
Name / Birth Date / School Schedule (please be specific)APPLICANT CERTIFICATION
I certify I am the parent, legal guardian, or foster parent for the child(ren) I am requesting child care assistance. I hereby certify that all information made on or in connection with this application is true and complete to the best of my knowledge. I understand that if I deliberately enter false information on this form, I may receive a $10,000 fine, imprisonment for not more than two years, or both. I also understand that any misrepresentation or concealment of material fact will be sufficient grounds for rejection of my application or suspension from any KTC program and/or services.
Applicant Signature Date Spouse/Significant Other/Guardian Signature Date
Page 1 of 11
PARENT RESPONSIBILITIES
Please initial each statement below indicating that you understand and agree to adhere to the following program requirements:
_____I have received and agree to comply with the Child Care Policies & Procedures.
_____I will provide all requested documentation necessary to verify eligibility.
_____I understand that child care assistance is for use only when I am engaged in authorized activities.
_____I understand it is my responsibility to pay for child care costs incurred until I qualify for child care assistanceand
receive a child care authorization.
_____I understand that I must be employed at least 20 hours per week, each week, to maintain my eligibility for child care assistance. I understand that Ineed to immediately notify the Child Care Assistance program if my work hours drop below 20 hours per week.
_____I understand any costs incurred exceeding the authorized amount or the monthly maximum is my responsibility.
_____I agree to sign my billing report on the last working day of the month.
_____I agree to immediately notify the Child Care Assistance Program within 5 days of ANY changes in marital status, household status, employment, training, income, or any other factors that will affect my eligibility for theprogram.
_____I understand I must report any additional income that I may receive in the future. This includes, but is not limited to payments such as child support, alimony, social security, foster care, cash gifts, etc.
_____I agree to renew my Child Care Authorization prior to expiration. I understand any child care costs, outside theeffective dates, is my responsibility.
_____I understand in order to change my current provider, I must submit a letter of termination to KTC and my
provider.
_____I am aware of the debarment process and understand that it will be utilized if I fail to pay my child carecost, submit my timesheets/pay stubs, or fail to comply with the Child Care Policies & Procedures.
_____I will inform the Child Care Assistance Program if I am no longer using child care services.
_____I understand that Parents and Child Care Providers who do not adhere to the policies and procedures of the Child Care Assistance Program may be debarred from the program.
CERTIFICATION STATEMENT
I certify that I have read and understand my responsibilities under the KTC Child Care Assistance Program. I understand that it is fraud to misrepresent facts in order to receive program benefits, including facts on income status, living arrangements, or working status. I understand that any fraud may result in removal from the KTC Child Care Assistance Program, and I will have to repay any wrongfully used funds as stated in 4 AAC 65.411 of the State Administrative Code.
Applicant Signature Date
Spouse/Significant other/Guardian Signature Date
Page 1 of 11
KNIK TRIBE CHILD CARE CENTER APPLICATION
Dear Child Care Provider:
As a child care provider for families who are receiving child care assistance through Knik Tribal Council’s Child Care Assistance Program, you are considered an independent contractor. Payments will thereby be made to you, as such. All record keeping matters concerning this taxable income is the provider’s sole responsibility. Our accounting department will mail a 1099 form to all providers earning over $600 per year at the end of the calendar year, (excluding corporations). As an independent contractor and child care provider, your signature acknowledges and accepts these responsibilities.
To receive payment for child care services that have been provided, Attendance and Billing Reports for each family must be completed, signed and submitted to Knik Tribal Council within 5 working days of the last day of each month. Please make sure reports are legible and accurate for easy processing. All checks are processed and mailed within 30 days from the date we receive the billing report if the parenthas provided all of their required documentation; such as, quarterly renewals or changes in employment, etc.. The parent must submit the required documents within 60 days from the date we receive your billing report. Failure to do so will result in the parent being solely responsible for the entire amount owed for child care services; as well as, any additional charges which may have accrued.
Please review and note the authorized charges and subsidy rate for each family. Parents are solely responsible for any unauthorized charges incurred.
Parents must renew their child care assistance applications quarterly, by the end date written on the bottom of the KTC Child Care Authorization. The renewal periods are every March, June, September, and December. If the parent does not renew their child care assistance, all child care costs accrued after the end date of the last authorization will not be covered by our program. It is the parent’s responsibility to remember these dates, as we do not send reminders.
Parents and Child Care Providers who do not adhere to the policies and procedures of the Child Care Assistance Program may be debarred from the program.
Page 1 of 11
REGISTRATION AND RATE SHEET
Check one:(please provide proof of liability insurance and a completed W-9 form)
Licensed Center (Non-residential setting)
Licensed Child Care Home
Check one (please provide a copy of your license or approval certification along with this application):
Municipal Child Care License Approval Certification State of Alaska LicenseMilitary License
Are you related to the child(ren)? Yes No If yes, please explain the relation:
Registration fee: Yes No ($75.00 Maximum paid to Center’s & Licensed providers only) $
Please list the days & hours you provide care:
Please list your rates (and the age range if different from below) for the following categories.
Age Range: / Infant0 – 18 Months / Toddler
19 – 36 Months / Child
37 Months – 6 yrs. / School Age
7 – 12 years
Full-time Enrollment:
5 full-time days a week / $ / $ / $ / $
Part-time Enrollment:
5 part-time days a week / $ / $ / $ / $
Full-time Daily Rate:
5+ to 10 hours a day / $ / $ / $ / $
Part-time Daily Rate:
0 - 5 hours per day / $ / $ / $ / $
Hourly Rate: / $ / $ / $ / $
Do you provide Child Care for Developmentally Disabled children? Yes No
Please list your DD rates:
Do you charge for holidays and/or closures? (KTC will pay for only ten scheduled closures annually on an enrollment lease list:
Please list whether the clients child(ren) are consider school age, infant, etc.:
Provider SignatureDate
Page 1 of 11
PROVIDER RESPONSIBILITIES
I have received and agree to comply with the KTC Child Care Policies & Procedures.
____I understand that as a provider, I function as an independent contractor, so I must comply with all applicable federal, state and local laws and regulations.
____I agree to provide a current: approval certification, municipal child care license, State of Alaska license, or military license in order to offer child care services; and, I will not receive payment for child care services if I do not have the required licenses or approval certification on file with the KTC Child Care Assistance Program; and I understand that KTC’s Child Care Authorization will become null and void in any event that my license expires or is revoked.
____I agree to provide child care services to the parent when they have a valid Child Care Authorization, and, I certify that the parent(s) will have unlimitedaccess to the facility whenever their children are in my care.
____I certify that space is available to meet the parent’s work and/or training schedule listed on the Child Care Authorization; and, that it is my responsibility tomake alternate arrangements in the event of an unscheduled facility closure.
____I agree to submit a true & correct Facility Attendance and Billing Report; and,all absences must be indicated, in order for the payment to be calculated on the basis of authorized days of care provided in the Child Care Authorization; and, I understand that I will not receive payment for child care before the effective date or after the expiration or revocation date.
____I understand that it is the parent’s full responsibility to make payment for services provided to the parent(s) which are outside the schedule outlined on the Child Care Authorization. I also understand that hours not listed on the Child Care Authorization, will not be included on the Facility Attendance and Billing Report.
____I understand that as a provider, I will be paid the maximum authorized monthly subsidy rate ofthe state market rate; and, parents are responsible for any additional charges whichexceed the maximum authorized monthly subsidy rate. I also understand that as a secondary provider, (authorized only when the primary provider is temporarily unavailable), payment is limited to the amount remaining after deducting the payment to the primary provider from the monthly maximum subsidy rate. I understand that the parent(s) are responsible for paying any additional balance due.
____I will charge the KTC parent(s) the same rate that I charge non-subsidized parents for the same service; and, I agree not to discriminate against a parent on the basis of race, color, national origin, age, or sex.
____I agree to submit any rate changes to the parent(s) and to KTC 30-calendar days before the effective date of change. Knik Tribe follows the State of Alaska Rates.
____I understand the Child Care Assistance Program has 30 calendar days to process payment. I understand the Child Care Assistance Program will not accept any inquiries in regards to payment prior to 30 calendar days.
____I understand that Parents and Child Care Providers who do not adhere to the policies and procedures of the Child Care Assistance Program may be debarred from the program.
I certify I have read and agree to my responsibilities under the KTC Child Care Assistance Program. I agree it is fraud to misrepresent facts in order to receive funds for child care services. I understand that committing fraud will result in removal from the Child Care Assistance Program and I will repay any funds wrongfully obtained as stated in 4 AAC 65.411 of the Alaska Administrative Code.