Redetermination PacketH O W TO P R O P E R LY C O M P L E T E A N E L C R E D E T E R M I N AT I O N PA C K E T

Child Care Application

Full name and current address are required

SSN, DOB and Race

Only for second parent if living in the home

Marital status is required

Childs full name, last 4 of SSN, DOB, Race and Relationship to client

Name, address and phone number for provider(s) are required

Must have complete names, address, birthdates, last 4 of the social, marital status, complete provider info, persons living in the home.

List all children not receiving or applying for services, Boyfriend, other family members that client provides sole support for

Full name, last 4 of SSN, DOB, Race and Relationship to Client

Signature and Dates are required on all pages

Child Care Application

Must have complete names, address, birthdates, last 4 of the social, marital status, complete provider info, persons living in the home.

Income WorksheetEarned and Unearned income

Employer info, pay frequency, amount and work schedule

School info and schedule

Signature and Dates are required on all pages

List any outgoing support payments

List all unearned income, child support, SSI, unemployment ect.List name of family member receiving income

Assistance received

Income WorksheetEarned and Unearned income

Verification of Employment

Must be completed with all boxes filled

Verification of Employment

If employment has changed since last redetermination Loss of Income must be completed by previous employer

This section is to be completed by EMPLOYER only

List last 6 weeks of pay by date, gross income, hours worked

Employer must sign and date.Information provided will be verified by ELC worker.

Child Support

Signature and Dates are required on all pages

Provide Child Support infoAll children in the home must be listed

Either under receiving CS or not receiving CSAbsent parent must be listed

Change of Address

Change of Address form only needed when changing addressClient must provide new proof of address

Signature and Dates are required on all pages

Family Needs Assessment Forms

Family Needs Assessment requested to outlineany additional needs the family may have

Signature and Dates are required on all pages

Terms & Conditions

Signature and Dates are required on all pages

If both parents live in the home both must sign T&C

Rights and Responsibilities

Signature and Dates are required on all pages

•All pages must be signed and dated

•No whiteout can be used on any document in the packet

• Supporting documents must be provided for any earned or unearned income, or deductions

• Packet must be received 30 days prior to the clients redetermination date

• The client will have 10 calendar days from the date of notice to provide any missing documents

•Any falsified documents used to gain services will cause immediate termination of services

•Any changes to clients family, income or employment status must be reported within 10 days (including pending maternity leave)

• Packets can be mailed or dropped off at the local service center

Checklist and Additional documents

Authorized hours of careFULL-TIME PART-TIME

Parents who are

• Full-time employees (working 30 hours or more)

• Full-time students • Disabled caregivers• Referral based clients (BG1,3,5)

depending on hours allowed per referral

They will receive

• At least six hours, but no more than 11, of child care or early childhood education services within a 24-hour period

Parents who are

• Part-time employees (working 20-29.9 hours)

• Part-time students• Job Seekers• Title V clients looking for

employment

They will receive

• Fewer than six hours of child care or early childhood education services within a 24-hour period