STATE OF COLORADO
Contents
1. understand this authorization shall be in effect unless rescinded by me in writing Provider s Signature Provider ID Number Date STATEMENT OF CRIMINAL HISTORY Please attach an additional sheet if necessary 1 Has any member of your household been arrested or convicted of a crime Yes No 2 Has any member of your household been investigated charged with or convicted of child abuse neglect or child molestation Yes No If you answered yes to either or both questions above you must provide the household members name copies of any pertinent court documents and a detailed explanation of the circumstances certify that the information provided is accurate and complete am aware that a fingerprint based background check will be performed Any arrests convictions for any degree of crime violent or non violent may result in the county not entering into or ending a fiscal agreement for a qualified family child care home provider Provider s Signature Date Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty of perjury in the second degree as defined in section 18 8 503 C R S and upon conviction thereof shall be punished accordingly DCC QUALIFIED 05 2013 Use additional page s if needed LARIMER Qualified Form 1 page s ay N COUNTY Page 19 of 27 LCHS 4286 Intentional Blank Page Page 20 of 272. schedule for Larimer County Provider Signature Date Provider ID LCHS 4297 09 12 SS 67 Qualified Family Child Care Home Fiscal Agreement v 6 0 R 11 10 Page 8 of 27 DEPARTMENT OF HUMAN SERVICES Child Care Assistance Program 1501 Blue Spruce Drive Fort Collins CO 80524 970 498 6300 COMMITTED TO EXCELLENCE Fax 970 498 7987 Dear Child Care Provider You have a choice of how you will receive your child care payment Below are the choices you have and a little information about each choice Direct Deposit e Your payment will go directly into your checking or savings account The first month may need to be on a Colorado Quest Card The following month your payment will go to your bank account With Direct Deposit your payment should be available to you the Wednesday or Thursday after our payroll closes Colorado EBT Quest Card e The Quest Card is issued to you and your childcare payments are put on the card The card is somewhat like a debit card You can access your money at grocery stores other retailers and ATM s remember ATM s do charge a fee which would reduce your amount You will have access to your money on the Monday after our payroll closes This is the fastest way to get your payment You will need to come into our Fort Collins office to get your card and to select your Personal Identification Number PIN If you already have an EBT Quest Card your childcare payments can be added to
3. 60 calendar days following the end of the month of care The provider forfeits payment for services billed manually if the care could have been paid through the automated payment process Never keep in their possession whether at the location where care is provided or in any other place a client s CCAP Card Understand that if the provider commits fraud or an intentional program violation the provider will be subject to disqualification from the Colorado Child Care Assistance Program CCCAP as a provider for 12 months for the first offense 24 months for the second offense and permanently for the third offense Grant the Department the authority to inspect the location s where care is provided for the presence of CCAP Cards or any other suspicious billing information Upon discovery of these materials the provider understands the Department has the right to seize these materials including the CCAP Cards and or POS Device LCHS 4297 1 15 33 Return any overpayment All overpayments will be recovered including but not limited to inaccurate or fraudulent billing If at the time any overpayment is established while your fiscal agreement is active the amount of the overpayment will be deducted beginning with the next child care payment and every payment thereafter until the overpayment is paid in full unless negotiated otherwise by the county through a signed repayment agreement The county shall collect the overpayment in accordance with s
4. AFFIDAVIT for the Colorado Department of Human Services as Proof of Lawful Presence in the United States I swear or affirm under penalty of perjury under the laws of the State of Colorado that check one Iam a United States citizen or I am a legal Permanent Resident of the United States or I am lawfully present in the United States pursuant to federal law I understand that this sworn statement is required by law because I have applied for a public benefit I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit I further acknowledge that making a false fictitious or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18 8 503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received A public benefit is any grant contract loan professional license or commercial license provided by an agency of a State or Local Government or by Appropriated Funds of a State or Local Government as provided in 8 U S C 1621 Signature Page 21 of 27 Intentional Blank Page Page 22 of 27 AFFIDAVIT for the Colorado Department of Human Services as Proof of Lawful Presence in the United States I swear or affirm under penalty of perjury under the laws of the State of
5. C Corporation S Corporation Trust estate Limited Liability Company LLC If the person identified on the Name line is an LLC check the Limited liability company box only and enter the appropriate code for the U S federal tax classification in the space provided If you are an LLC that is treated as a partnership for U S federal tax purposes enter P for partnership If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation enter C for C corporation or S for S corporation as appropriate If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301 7701 3 except for employment and excise tax do not check the LLC box unless the owner of the LLC required to be identified on the Name line is another LLC that is not disregarded for U S federal tax purposes If the LLC is disregarded as an entity separate from its owner enter the appropriate tax classification of the owner identified on the Name line Other entities Enter your business name as shown on required U S federal tax documents on the Name line This name should match the name shown on the charter or other legal document creating the entity You may enter any business trade or DBA name on the Business name disregarded entity name line Exemptions If you are exempt from backup withholding and or FATCA reporting enter in the Exemptions box any code
6. Card from your local Social Security Administration office or get this form online at www ssa gov You may also get this form by calling 1 800 772 1213 Use Form W 7 Application for IRS Individual Taxpayer Identification Number to apply for an ITIN or Form SS 4 Application for Employer Identification Number to apply for an EIN You can apply for an EIN online by accessing the IRS website at www irs gov businesses and clicking on Employer Identification Number EIN under Starting a Business You can get Forms W 7 and SS 4 from the IRS by visiting IRS gov or by calling 1 800 TAX FORM 1 800 829 3676 If you are asked to complete Form W 9 but do not have a TIN apply for a TIN and write Applied For in the space for the TIN sign and date the form and give it to the requester For interest and dividend payments and certain payments made with respect to readily tradable instruments generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments The 60 day rule does not apply to other types of payments You will be subject to backup withholding on all such payments until you provide your TIN to the requester Note Entering Applied For means that you have already applied for a TIN or that you intend to apply for one soon Caution A disregarded U S entity that has a foreign owner must use the appropriate Form W 8 Part Il Certification To establish to the w
7. Colorado that check one Iam a United States citizen or I am a legal Permanent Resident of the United States or I am lawfully present in the United States pursuant to federal law I understand that this sworn statement is required by law because I have applied for a public benefit I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit I further acknowledge that making a false fictitious or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18 8 503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received A public benefit is any grant contract loan professional license or commercial license provided by an agency of a State or Local Government or by Appropriated Funds of a State or Local Government as provided in 8 U S C 1621 Signature Page 23 of 27 Intentional Blank Page Page 24 of 27 SS 31 COLORADO DEPARTMENT OF HUMAN SERVICES CHILD CARE STANDARDS FOR QUALIFIED PROVIDERS SELF ASSURANCE FORM CLIENT ACKNOWLEDGEMENT Provider Name Provider Care will be provided by J Relative Provider Non Relative Provider Where J Qualified Providers Home J Child s Home Provider please answer each of the following questions by placing an X i
8. Last Name Legal First Name Middle Initial Alias AKA or Previous Name s Last Name First Name Middle Initial Date of Birth I I Age Soc Sec Gender __ Relationship to provider Signature Date 3 Legal Last Name Legal First Name Middle Initial Alias AKA or Previous Name s Last Name First Name Middle Initial Date of Birth I I Age Soc Sec Gender __ Relationship to provider Signature Date 4 Legal Last Name Legal First Name Middle Initial Alias AKA or Previous Name s Last Name First Name Middle Initial Date of Birth I l Age Soc Sec Gender Relationship to provider Signature Date See other side Page 17 of 27 LCHS 4286 Please complete this form and submit it with fingerprint card s and fees any time a new person moves into your home who is 18 years of age or older or if you have a child in your home who turns 18 during your contract period if care is ever provided in your home You and each adult 18 years of age or older who resides in your home as described above shall be subject to a fingerprint based criminal history records check along with a review of the state administered database for child abuse and neglect Counties may choose to also review this database for household members under the age of 18 What happens next In order to protect children in the State of Colorado there are some steps that need to
9. TIN If you fail to furnish your correct TIN to a requester you are subject to a penalty of 50 for each such failure unless your failure is due to reasonable cause and not to willful neglect Civil penalty for false information with respect to withholding If you make a false statement with no reasonable basis that results in no backup withholding you are subject to a 500 penalty Criminal penalty for falsifying information Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and or imprisonment Misuse of TINs If the requester discloses or uses TINs in violation of federal law the requester may be subject to civil and criminal penalties Specific Instructions Name If you are an individual you must generally enter the name shown on your income tax return However if you have changed your last name for instance due to marriage without informing the Social Security Administration of the name change enter your first name the last name shown on your social security card and your new last name If the account is in joint names list first and then circle the name of the person or entity whose number you entered in Part of the form Sole proprietor Enter your individual name as shown on your income tax return on the Name line You may enter your business trade or doing business as DBA name on the Business name disregarded entity name line Partners
10. an affidavit of citizenship and supporting documentation to the Department Sign an attestation of mental competence declaring no one in the home where the care is provided has been determined to be insane or mentally incompetent by a court of competent jurisdiction or specifically declaring the mental incompetence or insanity is not of such a degree that the provider cannot safely operate as a qualified provider Notify the Department within ten 10 calendar days of any circumstances resulting in the presence of a new adult age 18 and over or a minor turning 18 in the provider s residence where care is provided Allow parents or adult caretakers immediate access to the child ren in care Accept referrals for child care without discrimination with regard to race color national origin age sex religion or physical or mental handicap Provide children with adequate food shelter and rest Maintain as strictly confidential all information concerning children and their families Protect children from abuse neglect and report any suspected child abuse and neglect to the Department Hold the Colorado Department of Human Services the State of Colorado and the County Department of Human Services harmless for any loss or actions caused by the performance of this Agreement Offer a free age appropriate alternative to voluntary activities Provide child care at the address listed above and ensure that care is provided only by the person or busi
11. be completed in order for Larimer County Department of Human Services to complete the fiscal agreement process with you These steps must be completed within 30 days Once you have had your fingerprints taken you need to mail all of the enclosed forms and fingerprint card s to The Office of Early Childhood Division of Early Care and Learning CCCAP Program in the provided envelope along with a cashier s check or money order made out to the Colorado Department of Human Services CDHS for the total of all fees no personal checks are accepted Please use the check list at the end of this letter to ensure that you have mailed all required documents Fingerprint Cards You must take the enclosed fingerprint card s with you to the Larimer County Sheriff s Department Do not bend tear or soil the card Please leave all fields blank This information will be printed on the card by the Sheriff s Department e The Larimer County Sheriffs Department is located at 2501 Midpoint Drive in Fort Collins e Fingerprinting hours are from 8 00 a m to 4 30 p m Monday thru Friday Phone 970 498 5100 e There will be a 20 00 charge cash only that must be paid before prints can be taken Processing of Fingerprint Cards The following fees must be paid for the processing of the fingerprint cards The worksheet below details these fees These fees must be paid with a cashier s check or money order made out to the Colorado Department of Human Service
12. income even after the payee has otherwise become a U S resident alien for tax purposes If you are a U S resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U S tax on certain types of income you must attach a statement to Form W 9 that specifies the following five items 1 The treaty country Generally this must be the same treaty under which you claimed exemption from tax as a nonresident alien 2 The treaty article addressing the income 3 The article number or location in the tax treaty that contains the saving clause and its exceptions 4 The type and amount of income that qualifies for the exemption from tax 5 Sufficient facts to justify the exemption from tax under the terms of the treaty article Example Article 20 of the U S China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States Under U S law this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years However paragraph 2 of the first Protocol to the U S China treaty dated April 30 1984 allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States A Chinese student who qualifies for this exception under paragraph 2 of the first protocol and is relying on this excep
13. on foreign partners share of effectively connected income and 4 Certify that FATCA code s entered on this form if any indicating that you are exempt from the FATCA reporting is correct Note If you are a U S person and a requester gives you a form other than Form W 9 to request your TIN you must use the requester s form if it is substantially similar to this Form W 9 Definition of a U S person For federal tax purposes you are considered a U S person if you are e An individual who is a U S citizen or U S resident alien e A partnership corporation company or association created or organized in the United States or under the laws of the United States e An estate other than a foreign estate or e A domestic trust as defined in Regulations section 301 7701 7 Special rules for partnerships Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners share of effectively connected taxable income from such business Further in certain cases where a Form W 9 has not been received the rules under section 1446 require a partnership to presume that a partner is a foreign person and pay the section 1446 withholding tax Therefore if you are a U S person that is a partner in a partnership conducting a trade or business in the United States provide Form W 9 to the partnership to establish your U S status and avoid sec
14. paid the rates agreed upon in the attached Exhibit Fiscal Agreement Rate Information LCHS 4297 1 15 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Attend a county face to face training before the provider will receive a Point Of Service POS device before the fiscal agreement may begin and before the provider may bill the county for care The provider may be required to attend additional county face to face training at the discretion of the county Understand this fiscal agreement is effective on or after the date the county receives the signed fiscal agreement from the provider all additional required forms and documentation and the provider attended a live face to face POS training Providers will not be reimbursed for any care provided before this fiscal agreement start date and after this fiscal agreement end date The provider is required to use the POS device to transmit recorded attendance and as the billing mechanism for care provided Maintain a land based phone service to ensure the POS terminal is able to transmit attendance information to the Department for payment on a daily basis The provider shall not hold any parent or adult caretaker responsible for the cost of care if the transactions are not transmitted timely Store and Forward SAF transactions must be transmitted timely for payment Ensure the parent or adult caretaker swipes his her card to check the child ren in
15. the assurances above and understand the following statements This provider is not required to obtain a child care license or meet monitoring requirements for licensed providers by Colorado law The parent assumes the responsibility to monitor the care provided to the child Non licensed providers may apply for a license if they choose to do so The local county department will make information available to parents on how to assess and choose child care settings Client s Signature Date Client s Printed Name LCHS 4263 615 82 14 6314 rev 5 2013 White Provider Copy LARIMER Yellow Client Copy A COUNTY Pink County Copy fe Page 25 of 27 Intentional Blank Page Page 26 of 27 Provider Information Bulletin Child Care Assistance Program From CHATS Implementation Team Date July 1 2010 Re Provider Training and Registration Mandatory Provider Training and Class Registration Information The new Childcare Assistance Tracking System or CHATS has been implemented in five pilot counties in the State which include El Paso Lincoln Larimer Summit and Weld counties This is the system that is used to track attendance that generates payment to child care providers that accommodate the State s Child Care Assistance Program CCAP To CCAP Providers It was also introduced that the State is requiring all providers to attend a Provider Training Workshop Licensed Child Care Centers Licensed Family Child Care Homes and Qu
16. to learn more about identity theft and how to reduce your risk Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons including federal agencies who are required to file information returns with the IRS to report interest dividends or certain other income paid to you mortgage interest you paid the acquisition or abandonment of secured property the cancellation of debt or contributions you made to an IRA Archer MSA or HSA The person collecting this form uses the information on the form to file information returns with the IRS reporting the above information Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities states the District of Columbia and U S commonwealths and possessions for use in administering their laws The information also may be disclosed to other countries under a treaty to federal and state agencies to enforce civil and criminal laws or to federal law enforcement and intelligence agencies to combat terrorism You must provide your TIN whether or not you are required to file a tax return Under section 3406 payers must generally withhold a percentage of taxable interest dividend and certain other payments to a payee who does not give a TIN to the payer Certain penalties may also apply for providing false or fraudulent information Page 16 of 27 County Name Provider ID Colorado Dep
17. your existing card PLEASE SELECT ONLY ONE OF THE FOLLOWING CHOICES Q Icurrently receive direct deposit and would like to continue Q Direct Deposit into Checking or Savings account please fill out the form ACH FORM FOR COLORADO PROVIDERS For Direct Deposit Payments amp return it with your packet Q Check here if you already have an EBT Card and would like your childcare payments added on to your card 0 New Colorado EBT Quest Card Contact Gail Graham at 498 7623 Pick up your Colorado EBT Quest Card at Larimer County Department of Human Services 1501 Blue Spruce Drive Fort Collins CO 80524 Bring a picture I D Provider Signature Date Social Security Number or Provider ID LCHS 4220 07 10 Page 9 of 27 Intentional Blank Page Page 10 of 27 ACH FORM FOR COLORADO PROVIDERS FOR DIRECT DEPOSIT PAYMENTS TO PROVIDERS I we hereby authorize J P Morgan Electronic Financial Services Inc JPMorgan EFS as designated agent for the Colorado Department of Human Services CDHS to initiate credit entries and if necessary reverse any incorrect EFT credit entries made in error to the bank account indicated below in accordance with standard banking procedures for payments related to the Colorado Electronic Benefits Transfer EBT program 498 m aN Ae sihin aserat senan Aisne ia IRI neil are CC Foster Adoptive CW Colo Works TANF COIN 9digit LEAP LE Nursing Home NH CORE CASE
18. 297 09 12 SS 67 Qualified Family Child Care Home Fiscal Agreement v 6 0 R 11 10 Page 7 of 27 Part Time Alternative Rates up to 5 00 hours per day Rate Type Oto6 6 to 12 12 to 18 18 to 24 24 to 30 30 to 36 36 months School Age months months months months months months to School Age Alternative 8 80 8 80 8 80 8 80 8 80 8 80 8 80 8 80 Part Time Full Time Alternative Rates 11 01 to 17 00 hours per day Rate Type Oto6 6 to 12 12 to 18 18 to 24 24 to 30 30 to 36 36 months School Age months months months months months months to School up to 13 Age birthday Alternative 24 80 24 80 24 80 24 80 24 80 24 80 24 80 24 80 Full Time Full Time Alternative Rates 17 01 to 23 59 hours per day Rate Type Oto6 6 to 12 12 to 18 18 to 24 24 to 30 30 to 36 36 months School Age months months months months months months to School up to 13 Age birthday Alternative 32 00 32 00 32 00 32 00 32 00 32 00 32 00 32 00 Disability rates will be reviewed by Larimer County CCAP Rates will vary based upon the type and severity of the child s needs according to the special needs policy in Larimer County Please have the parent contact their child care worker or coach for more information By signing this document the provider acknowledges receipt of the Colorado Child Care Assistance Program fee
19. CW3 Name of County Staff completing this section Phone of County Staff including area code YOUR NAME ADDRESS CITY STATE ZIP TELEPHONE NUMBER including area code FEDERAL E I N NUMBER gt sess OR SOCIAL SECURITY NUMBER 2 CHECK HERE IF THIS IS A REQUEST TO CHANGE BANKING INFO PREVIOUSLY SUBMITTED C If a change of banking information what is the effective date of this change TYPE OF ACCOUNT please check only one Checking attach voided check L Savings attach voided deposit sip __ ACCOUNT NUMBER NAME OF YOUR BANK TRANSIT ROUTING NUMBER Check with your bank to ensure that this number is correct for direct deposit TELEPHONE NUMBER FOR YOUR BANK This agreement is to remain in full force and effect until JPMorgan EFS as designated agent for CDHS has received written notification from the vendor provider of its termination in such time and manner to afford JPMorgan EFS a reasonable opportunity to act on it It is the responsibility of the vendor provider to fill out and submit a new Authorization Agreement to CDHS if the vendor provider changes banks or accounts Provider Signature Date Please return this form to Accounting Child Care Larimer County DHS 2601 Midpoint Drive Suite 112 Fort Collins Colorado 80525 Page 11 of 27 Rev 04 30 2004 Intentional Blank Page Page 12 of 27 Form W 9 Rev August 2013 Department of the Treasury Internal Revenue Service Request for Taxpaye
20. STATE OF COLORADO cdhs Colorado Department of Human Services people who help people OFFICE OF EARLY CHILDHOOD Mary Anne Snyder Director John W Hickenlooper DIVISION OF EARLY CARE AND LEARNING David A Collins Director Reggie Bicha 1575 Sherman Street 1 Floor Executive Director Denver Colorado 80203 1714 Phone 303 866 5958 www colorado gov cdhs Thank you for your willingness to be a Qualified Family Child Care Home Provider for the Colorado Child Care Assistance Program CCCAP Your County Department of Human Social Services will work with you and the State CCCAP team to process your application Here is the process 1 The following must be completed and received by the Larimer County Department of Human Services to begin the approval process Approval to become a Qualified Provider cannot be considered until we receive everything listed below filled out completely and or signed Please use the check boxes to assist you in preparing your mailing to us Qualified Family Child Care Home Provider Fiscal Agreement Payment Choice Letter W 9 We only need page 1 back Qualified Family Child Care Home Provider Information Form Authorization to Supply Information Affidavit of Citizenship To be completed by the applicant and spouse significant other Self Assurance Form This form requires the client parent of child signature also 0 O D D D DDO Copy of Driver s License or government issued ID with curr
21. account The minor The grantor trustee The actual owner The owner The grantor Give name and EIN of Oo 11 12 List first and circle the name of the person whose number you furnish If only one person on a Disregarded entity not owned by an individual A valid trust estate or pension trust Corporation or LLC electing corporate status on Form 8832 or Form 2553 Association club religious charitable educational or other tax exempt organization Partnership or multi member LLC A broker or registered nominee 13 Account with the Department of Agriculture in the name of a public entity such as a state or local government school district or prison that receives agricultural program payments Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 see Regulation section 1 671 4 b6 2 i B The owner Legal entity The corporation The organization The partnership The broker or nominee The public entity The trust joint account has an SSN that person s number must be furnished Circle the minor s name and furnish the minor s SSN You must show your individual name and you may also enter your business or DBA name on the Business name disregarded entity name line You may use either your SSN or EIN if you have one but the IRS encourages you to use your SSN E List first and circ
22. alified Family Child Care Homes You should already be working with your County on a new Fiscal Agreement and Point of Service POS Agreement in order to remain a CCAP Provider THIS IS A REQUIREMENT IN ORDER TO BE CONTRACTED WITH LARIMER COUNTY To register for the classes below please contact the registration person listed below Providers may attend any of the trainings offered If you have any questions about training Fiscal or POS Agreements or general questions about the new system please email CHATS ReplacementProject state co us Thank you Larimer County CCAP Gail First Wednesday of Room 124 970 498 7623 each month 2573 Midpoint Drive Suite 108 or Fort Collins CO 80525 Karen 1 30 p m 970 498 7627 LCHS 5566 04 13 Page 27 of 27
23. artment of Human Services Division of Early Care and Learning QUALIFIED FAMILY CHILD CARE HOME PROVIDER INFORMATION FORM State CCCAP Processing Only All sections of this form must be completed signed with fingerprints properly completed see instructions and proper fee included Any omissions or errors may result in the entire application packet being returned to the county Please be sure to review your submission carefully 1 Provider Name Please PRINT Clearly Legal Last Name Physical Address Legal First Name Middle Initial City State Zip Code Mailing Address if different City Are you lawfully present in the United States Yes No Date of Birth month day year Soc Sec State Zip Gender Alias AKA or Previous Name s Home phone Work Cell Phone attest that no one in the home where the care is provided has been determined to be insane or mentally incompetent by a court of competent jurisdiction or specifically that the mental incompetence or insanity is not of such a degree that cannot safely operate as a qualified provider Signature Date OTHER PERSONS IN YOUR HOME Include all relatives non relatives and temporary residents regardless of age Only persons 18 years of age and older must sign this form Are you adding individual s to a previously approved provider s household Yes No 2 Legal
24. d within fifteen 15 calendar days and in good condition allowing for normal wear and tear to Xerox the Department will establish a recovery for the POS device which is 365 Maintain sign in out sheets for children in care These records shall be maintained for three years plus the current year and are to be made available to the Department upon request even if the provider no longer has an open Fiscal Agreement The sign in out sheets must include no less than the date of care the full name of the child ren accurate sign in time authorized adult caretaker legible signature for sign in time accurate sign out time authorized adult caretaker legible signature for sign out time Sign in out times must be accurate and within five minutes of the time recorded on the POS device Maintain the original POS receipts for children in their care These records shall be maintained for three years plus the current year and are to be made available to the Department upon request Manually bill the Department for authorized services based on county payroll policies not reimbursed automatically based on approved POS transactions The provider shall provide sign in out sheets and all other requested information based on county policy to support requests for manual payment Counties may impose additional requirement regarding manual claims The provider forfeits payment for services if the original manual billing form is received by the county more than sixty
25. eceived by the Colorado Department of Human Services and all background checks have cleared If the paperwork is not complete or readable it will be sent back to you This will delay your potential start date as a Qualified Family Child Care Home Provider If someone in the household fails to clear the background check you cannot become a Qualified Family Child Care Home Provider for Larimer County Child Care Program Call 498 6300 if you need assistance Page 18 of 27 LCHS 4286 AUTHORIZATION TO SUPPLY INFORMATION hereby authorize the person agency or institution entered below to supply information requested by the Colorado Department of Human Services as a condition of contracting to provide Qualified Child Care with my local county department of social numan services and to allow the inspection and reproduction of records pertaining to me or any other household member understand based on the information received my local county department of social nhuman services may be unable to enter into a fiscal agreement with me 1 Colorado Department of Human Services Child Welfare Automated System 2 Colorado Bureau of Investigation 3 Federal Bureau of Investigation This authorization is given only in connection with its use by designated Colorado Department of Human Services employees and or designated employees of other agencies who will be accessing information to determine my eligibility to provide Qualified Child Care
26. eleven 11 calendar days notice This Agreement may be terminated without advance notice if a child s health or safety is endangered if the provider is under a negative licensing action if the Department has concerns involving the provider an employee or a resident in the provider s home or if the Department verifies the provider possesses any CCAP card s By signing this Agreement the provider acknowledges receipt of information regarding the rules and policies of the Colorado Child Care Assistance Program The effective date of this contract is no earlier than the date that the county receives and signs the Fiscal Agreement The provider shall receive a copy of the signed Fiscal Agreement CHILD CARE PROVIDER DEPARTMENT OF SOCIAL HUMAN SERVICES Marsha Ellis Print Name Date Authorized Representative Print Name Date Signature Signature 1501 Blue Spruce Drive Mailing Address Mailing Address City State Zip Phone Provider Email Address LCHS 4297 1 15 City State Zip Phone Qualified Provider Fiscal Agreement Rates Regular Care Care during standard business hours of 6 a m and 6 p m Full Time Rates 5 01 to 11 00 hours per day Rate Type Oto6 6 to 12 12 to 18 18 to 24 24 to 30 30 to 36 36 months School Age months months months months months months to School up to 13 Age birthday Regular 14 00 14 00 14 00 12 50 12 50 12 50 10 50 10 50 Part Time Rate
27. elines on whose number to enter Social security number Employer identification number Certification Under penalties of perjury certify that 1 The number shown on this form is my correct taxpayer identification number or am waiting for a number to be issued to me and 2 am not subject to backup withholding because a am exempt from backup withholding or b have not been notified by the Internal Revenue Service IRS that am subject to backup withholding as a result of a failure to report all interest or dividends or c the IRS has notified me that am no longer subject to backup withholding and 3 lam a U S citizen or other U S person defined below and 4 The FATCA code s entered on this form if any indicating that am exempt from FATCA reporting is correct Certification instructions You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return For real estate transactions item 2 does not apply For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retirement arrangement IRA and generally payments other than interest and dividends you are not required to sign the certification but you must provide your correct TIN See the in
28. ent legal name and address This is required for the applicant and the applicant s spouse significant other Please enlarge to 130 when making your copy See attached for other acceptable forms of ID E Copy of Social Security card with current legal name This is required for the applicant and the applicant s spouse significant other Please enlarge to 130 when making your copy E Point of Service POS Device Provider Agreement to be signed at POS training Return the paperwork to Child Care Accounting Larimer County Department of Human Services 2601 Midpoint Drive Suite 112 Fort Collins CO 80525 Please contact child care accounting at 498 7623 with any question you may have You must e Be eighteen 18 years of age or older e Agree to submit to a Fingerprint Based Criminal Background Check with the Colorado Bureau of Investigation CBI and Federal Bureau of Investigation FBI for yourself and all those who live in your home where the care will be given who are 18 years of age and older 3 Fill out the forms fingerprint card s carefully and thoroughly Please read the included instructions 4 Take the fingerprint card s provided to your local law enforcement agency for processing there may be a nominal charge for this service Page 1 of 27 5 Send the fingerprint card s required fees described below and a copy of the Qualified Family Child Care Home Provider Information Form to the state off
29. est an informal conference if s he disputes the termination of a Fiscal Agreement pursuant to 9 CCR 2503 1 at Section 3 912 4 Providers may request a conference in writing within 15 days of the date of the action This request should be addressed to the county director of the county Department of Social Human services responsible for the action The conference shall be held within two weeks of the date the request for a conference is received by the county The purpose of the conference is limited to discussion about the termination of the fiscal agreement pursuant to 9 CCR 2503 1 at Section 3 906 D The final decision of the county shall be mailed to the provider within 15 days of the conference date Department Agrees to Provide face to face training to the provider on how to use the Point of Service POS device prior to entering into a Fiscal Agreement with the provider 1 Enter the Fiscal Agreement into the Childcare Automated Tracking System CHATS within five 5 business days of receipt of the completed Fiscal Agreement and all supporting documentation 2 Determine client s eligibility for child care services within fifteen 15 days of receiving the complete application packet including verification 3 Send Child Care Authorization Notices to the provider within seven 7 working days of the Department s initial approval or prior to making any changes in eligibility for each child such as parental fees authorized am
30. ey can answer your questions and provide you with updates Name Phone Our Mission is to Design and Deliver Quality Human Services that Improve the Safety and Independence of the People of Colorado Rev 07 2013 LCHS 4226 09 13 LARIMER a COUNTY DEPARTMENT OF HUMAN SERVICES r Child Care Assistance Program COMMITTED TO EXCELLENCE 970 498 6300 Fax 970 498 7987 Page 2 of 27 Qualified Family Child Care Home Provider Fiscal Agreement Child Care Assistance Program License Certificate Provider ID Tax ID No SSN FEIN This Agreement is entered into and between the Larimer County Department of Human Services herein referred to as Department and Provider Name herein referred to as provider who will provide child care at the following address Provider Address This agreement shall be in effect from to Qualified Provider Agrees to the following 1 10 11 12 13 14 15 17 Submit to a fingerprint based criminal background check along with a review of the state administered database for child abuse and neglect and provide the names and fingerprints of all adults age 18 and over who reside in the provider s home where care is provided for the same purpose Report to the Department any changes in phone number and or address no less than ten 10 calendar days prior to the change Provide verification of Lawful Presence in the United States and provide
31. hip C Corporation or S Corporation Enter the entity s name on the Name line and any business trade or doing business as DBA name on the Business name disregarded entity name line Disregarded entity For U S federal tax purposes an entity that is disregarded as an entity separate from its owner is treated as a disregarded entity See Regulation section 301 7701 2 c 2 iii Enter the owner s name on the Name line The name of the entity entered on the Name line should never be a disregarded entity The name on the Name line must be the name shown on the income tax return on which the income should be reported For example if a foreign LLC that is treated as a disregarded entity for U S federal tax purposes has a single owner that is a U S person the U S owner s name is required to be provided on the Name line If the direct owner of the entity is also a disregarded entity enter the first owner that is not disregarded for federal tax purposes Enter the disregarded entity s name on the Business name disregarded entity name line If the owner of the disregarded entity is a foreign person the owner must complete an appropriate Form W 8 instead of a Form W 9 This is the case even if the foreign person has a U S TIN Note Check the appropriate box for the U S federal tax classification of the person whose name is entered on the Name line Individual sole proprietor Partnership
32. ice at the address below 6 Be prompt and timely with this paperwork the date it is received at the state Division of Early Care and Learning will be stamped on your Information Form and the date of receipt will affect the start date of CCCAP payments Please note If you are approved as a Qualified Family Child Care Home Provider for Larimer County CCAP the child care authorization begin date is not the date that the client applied for benefits It is the date that all forms are received and considered complete by the Colorado Department of Human Services This is not a guarantee and is dependent upon the final outcome of the background check After the requested paperwork is received we will conduct an internal background check If you pass our internal check you will be mailed additional information This will include instructions for completing the mandatory fingerprinting for every household member 18 and older The table below indicates fees charged by the Colorado Bureau of Investigation and the Federal Bureau of Investigation You will be responsible for payment of these fees if when you submit your fingerprint cards to the Colorado Department of Human Services DO NOT SEND FEES TO LARIMER COUNTY What happens next e A state CCCAP Specialist will review your Qualified Family Child Care Home Provider Information Form verify proper pre screening was completed by the county process the payment and submit the fingerprint card s t
33. id to an attorney and payments for services paid by a federal executive agency Exemption from FATCA reporting code The following codes identify payees that are exempt from reporting under FATCA These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions Therefore if you are only submitting this form for an account you hold in the United States you may leave this field blank Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements A An organization exempt from tax under section 501 a or any individual retirement plan as defined in section 7701 a 37 B The United States or any of its agencies or instrumentalities C A state the District of Columbia a possession of the United States or any of their political subdivisions or instrumentalities D A corporation the stock of which is regularly traded on one or more established securities markets as described in Reg section 1 1472 1 c 1 i E A corporation that is a member of the same expanded affiliated group as a corporation described in Reg section 1 1472 1 c 1 i F A dealer in securities commodities or derivative financial instruments including notional principal contracts futures forwards and options that is registered as such under the laws of the United States or any state Page 3 G A real estate
34. investment trust H A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 I A common trust fund as defined in section 584 a J A bank as defined in section 581 K A broker L A trust exempt from tax under section 664 or described in section 4947 a 1 M A tax exempt trust under a section 403 b plan or section 457 g plan Part I Taxpayer Identification Number TIN Enter your TIN in the appropriate box If you are a resident alien and you do not have and are not eligible to get an SSN your TIN is your IRS individual taxpayer identification number ITIN Enter it in the social security number box If you do not have an ITIN see How to get a TIN below If you are a sole proprietor and you have an EIN you may enter either your SSN or EIN However the IRS prefers that you use your SSN If you are a single member LLC that is disregarded as an entity separate from its owner see Limited Liability Company LLC on page 2 enter the owner s SSN or EIN if the owner has one Do not enter the disregarded entity s EIN If the LLC is classified as a corporation or partnership enter the entity s EIN Note See the chart on page 4 for further clarification of name and TIN combinations How to get a TIN If you do not have a TIN apply for one immediately To apply for an SSN get Form SS 5 Application for a Social Security
35. ithholding agent that you are a U S person or resident alien sign Form W 9 You may be requested to sign by the withholding agent even if items 1 4 or 5 below indicate otherwise For a joint account only the person whose TIN is shown in Part should sign when required In the case of a disregarded entity the person identified on the Name line must sign Exempt payees see Exempt payee code earlier Signature requirements Complete the certification as indicated in items 1 through 5 below 1 Interest dividend and barter exchange accounts opened before 1984 and broker accounts considered active during 1983 You must give your correct TIN but you do not have to sign the certification 2 Interest dividend broker and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983 You must sign the certification or backup withholding will apply If you are subject to backup withholding and you are merely providing your correct TIN to the requester you must cross out item 2 in the certification before signing the form 3 Real estate transactions You must sign the certification You may cross out item 2 of the certification 4 Other payments You must give your correct TIN but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN Other payments include payments made in the course of the requester s trade or business f
36. lable for both active and quiet play D FEEDING AND HEALTH CARE OF THE CHILDREN 1 Will you serve the children nutritious meals suited to the age and special needs of the children in care and to the period of time children are in care 2 Will you provide daily activities that promote normal physical mental social and emotional development of children and sufficient rest periods E NUMBER OF CHILDREN IN CARE a Qualified Care in the Child s Own Home When children are in care in their own home there is no limit to the number of children in care as long as they are all residents of that home b Qualified Care in the Qualified Providers Home Children in the home for whom the Provider is the legal guardian or parent are not limited AND e Relative provider may care for any number of children related to the provider as the grandparent brother sister step brother step sister uncle aunt niece nephew or cousin of the child by marriage blood court decree or adoption AND OR e Non relative provider may care for children from one family household in addition to children who are related to the Provider as above F REMARKS If you cannot agree to all of these assurances your application must be verified by the County Department and may result in non approval Provider s Signature Date Provider s Printed Name ATTENTION CLIENT QUALIFIED PROVIDER STATUS By signing below state that have reviewed
37. le the name of the trust estate or pension trust Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title Also see Special rules for partnerships on page 1 Note Grantor also must provide a Form W 9 to trustee of trust Page 4 Note If no name is circled when more than one name is listed the number will be considered to be that of the first name listed Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personal information such as your name social security number SSN or other identifying information without your permission to commit fraud or other crimes An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund To reduce your risk e Protect your SSN e Ensure your employer is protecting your SSN and e Be careful when choosing a tax preparer If your tax records are affected by identity theft and you receive a notice from the IRS respond right away to the name and phone number printed on the IRS notice or letter If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet questionable credit card activity or credit report contact the IRS Identity Theft Hotline at 1 800 908 4490 or submit Form 14039 For more information see Publication 4535 Identity Theft Prevention and Victi
38. m Assistance Victims of identity theft who are experiencing economic harm or a system problem or are seeking help in resolving tax problems that have not been resolved through normal channels may be eligible for Taxpayer Advocate Service TAS assistance You can reach TAS by calling the TAS toll free case intake line at 1 877 777 4778 or TTY TDD 1 800 829 4059 Protect yourself from suspicious emails or phishing schemes Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft The IRS does not initiate contacts with taxpayers via emails Also the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers passwords or similar secret access information for their credit card bank or other financial accounts If you receive an unsolicited email claiming to be from the IRS forward this message to phishing irs gov You may also report misuse of the IRS name logo or other IRS property to the Treasury Inspector General for Tax Administration at 1 800 366 4484 You can forward suspicious emails to the Federal Trade Commission at soam uce gov or contact them at www ftc gov idtheft or 1 877 IDTHEFT 1 877 438 4338 Visit IRS gov
39. ment trust 9 An entity registered at all times during the tax year under the Investment Company Act of 1940 10 A common trust fund operated by a bank under section 584 a 11 A financial institution 12 A middleman known in the investment community as a nominee or custodian 13 A trust exempt from tax under section 664 or described in section 4947 The following chart shows types of payments that may be exempt from backup withholding The chart applies to the exempt payees listed above 1 through 13 IF the payment is for THEN the payment is exempt for Interest and dividend payments All exempt payees except for 7 Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012 Barter exchange transactions and patronage dividends Exempt payees 1 through 4 Payments over 600 required to be reported and direct sales over 5 000 Generally exempt payees 1 through 5 Payments made in settlement of payment card or third party network transactions Exempt payees 1 through 4 See Form 1099 MISC Miscellaneous Income and its instructions However the following payments made to a corporation and reportable on Form 1099 MISC are not exempt from backup withholding medical and health care payments attorneys fees gross proceeds pa
40. n the appropriate box A PROVIDER Yes No 1 Do you have an interest in and knowledge of children and a concern for their proper care and well being 2 Have any of your own children ever been placed in foster care or a residential treatment facility 3 Are you at least 18 years of age Date of Birth 4 Do you have adequate physical stamina and mental capacity to meet the needs of the children 5 Are you free of other responsibilities and demands that would interfere with the provision of care individual attention and nurturing for the children in care 6 Are you experienced in the care of children knowledgeable of their needs and development and able to deal effectively with problems emergencies and discipline 7 Are you able to work cooperatively with the clients and agency in providing appropriate discipline care and direction for the children that will not be in conflict with parental practices 8 1 Are you willing to participate in training programs 2 Are you aware of the Back to Sleep Initiative that recommends all infants be put to sleep on their backs in order to reduce the incidence of Sudden Infant Death Syndrome SIDS B HOUSE AND YARD Is your house and yard maintained free from hazards to health and safety C EQUIPMENT Do you have materials and equipment appropriate for the age of children in care and in good repair that will be avai
41. ness listed above Provide care for children under this agreement only if authorized by the Department in advance Do not provide any unlicensed child care Violations of this nature will be reported to CDHS licensing staff Sign the child care Fiscal Agreement and all other county or state required forms Develop an individualized care plan for children with additional child care needs Notify the Department of unexplained frequent and or consistent absences within ten 10 calendar days of an established pattern Collect the full parental fee each month Parental fees are due to the provider from the parent or adult caretaker on the first of the month Providers shall report non payment of parental fees no later than the end of the month following the month the parental fees are due unless county policy requires it earlier The unpaid parental fees must be reported in writing by FAX email mail or on a manual claim form Not charge parents or adult caretakers rates in excess of those agreed upon as part of the Fiscal Agreement this includes the agreed upon registration activity transportation fees absences and holidays as set by Department policy The rate in the Fiscal Agreement is the maximum allowable rate of reimbursement for the care provided and includes any portion for which the parent or adult caretaker is responsible Providers may not receive payments for days in which they were not available to provide care The provider will be
42. o the Colorado Bureau of Investigations and the Federal Bureau of Investigations e The county representative will track the progress of the criminal background check CBC process and according to individual county policy proceed with entering your signed Fiscal Agreement in the system at the proper time e Your county representative will arrange for you to attend a training session required on the care and use of the Point of Service POS device and explanation of the payment system e When your Fiscal Agreement is entered in the system a POS device used for payments will be shipped to your physical address via FedEx within seven business days A signature at delivery is required FEES DUE With This Application NO CASH OR Personal CHECKS All fees must be in ONE payment CBI and FBI Fees 39 50 per person 18 yrs X No of persons Total Application Fee 10 00 for entire application one time only do not add for 10 00 additions to a previously cleared open Provider TOTAL of ONE Money Order or Cashier s Check NO CASH OR Personal Check Total of 2 boxes above Make Payable to CDHS Mail to Colorado Dept of Human Services Attn Qualified Provider 1575 Sherman St First Floor Denver CO 80203 In addition a 20 00 fee will be charged at the time of service by the Larimer County s Sheriff s Department for each set of fingerprints needed Keep in touch with your county representative Th
43. or rents royalties goods other than bills for merchandise medical and health care services including payments to corporations payments to a nonemployee for services payments made in settlement of payment card and third party network transactions payments to certain fishing boat crew members and fishermen and gross proceeds paid to attorneys including payments to corporations 5 Mortgage interest paid by you acquisition or abandonment of secured property cancellation of debt qualified tuition program payments under section 529 IRA Coverdell ESA Archer MSA or HSA contributions or distributions and pension distributions You must give your correct TIN but you do not have to sign the certification Page 15 of 27 Form W 9 Rev 8 2013 What Name and Number To Give the Requester For this type of account Give name and SSN of 1 2 3 4 Individual Two or more individuals joint account Custodian account of a minor Uniform Gift to Minors Act a The usual revocable savings trust grantor is also trustee b So called trust account that is not a legal or valid trust under state law Sole proprietorship or disregarded entity owned by an individual Grantor trust filing under Optional Form 1099 Filing Method 1 see Regulation section 1 671 4 b 2 i A For this type of account The individual The actual owner of the account or if combined funds the first individual on the
44. ount of care added or deleted children and or any other changes to child care arrangements 4 Exercise the Department option to reimburse the qualified child care provider for care from the date the accurately completed fingerprint packet supporting forms and correct fees for the provider s household are received by the CDHS Division of Early Care and Learning The qualified provider may continue to receive funds after that as long as the qualified provider and all qualified adults living in the residence show no evidence of criminal offenses or a pattern of misdemeanor offenses 5 Exercise the Department option to enter the Fiscal Agreement and make payments after the results are returned from the Colorado Bureau of Investigation and or Federal Bureau of Investigation The Department shall not pay for any care provided prior to the date the fingerprint based criminal background check results are returned The parent or adult caretaker shall be responsible for payment for care provided before the results are returned LCHS 4297 1 15 6 Reimburse the provider for authorized attended and properly recorded and transmitted child care in accordance with Colorado Child Care Assistance Program rules Payment to the licensed provider is the total cost of the lesser of authorized and attended care based on rates set by this Agreement minus the parental fee if applicable This Agreement may be terminated by either party by giving the other party
45. r Identification Number and Certification Give Form to the requester Do not send to the IRS Name as shown on your income tax return Business name disregarded entity name if different from above Check appropriate box for federal tax classification C individual sole proprietor C Corporation S Corporation O Other see instructions gt Exemptions see instructions Partnership O Trust estate O Limited liability company Enter the tax classification C C corporation S S corporation P partnership gt Exempt payee code if any Exemption from FATCA reporting code if any Address number street and apt or suite no Requester s name and address optional City state and ZIP code Print or type See Specific Instructions on page 2 List account number s here optional Part I Taxpayer Identification Number TIN Enter your TIN in the appropriate box The TIN provided must match the name given on the Name line to avoid backup withholding For individuals this is your social security number SSN However for a resident alien sole proprietor or disregarded entity see the Part instructions on page 3 For other entities it is your employer identification number EIN If you do not have a number see How to get a TIN on page 3 Note If the account is in more than one name see the chart on page 4 for guid
46. report all your interest and dividends on your tax return for reportable interest and dividends only or 5 You do not certify to the requester that you are not subject to backup withholding under 4 above for reportable interest and dividend accounts opened after 1983 only Certain payees and payments are exempt from backup withholding See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W 9 for more information Also see Special rules for partnerships on page 1 What is FATCA reporting The Foreign Account Tax Compliance Act FATCA requires a participating foreign financial institution to report all United States account holders that are specified United States persons Certain payees are exempt from FATCA reporting See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W 9 for more information Page 2 Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person For example you may need to provide updated information if you are a C corporation that elects to be an S corporation or if you no longer are tax exempt In addition you must furnish a new Form W 9 if the name or TIN changes for the account for example if the grantor of a grantor trust dies Penalties Failure to furnish
47. s CDHS FEES DUE WITH THIS APPLICATION CBI and FBI Fees 39 50 per person 18 years X No of persons Total of age or older Application Fee 10 00 for entire application one time only do not add for 10 00 additions to the household Submit one Certified Cashier s Check or Money Order for a total of Total of 2 boxes above Make the funds payable to CDHS County Please send a copy of this form original is submitted to the County fingerprint card s and fee to CDHS Division of Early Care and Learning 1575 Sherman St 1 Floor Attn CCCAP Denver CO 80203 Please save your receipts If you are approved as a Qualified Family Child Care Home Provider you may be eligible for reimbursement on some of the fees that you paid out What you need to mail to The Office of Early Childhood Division of Early Care and Learning CCCAP Program are 1 E Completed Qualified Family Child Care Home Provider Information Form 2 L Completed Authorization to Supply Information 3s 0O Fingerprint cards for every person living in your household 18 years of age or older 4 Payment via cashier s check or money order for the processing of the fingerprint cards no personal checks e Total Amount for the cashiers check or money e Payable to Colorado Department of Humans Services CDHS Please note that authorization for child care cannot begin until all forms and exact payment from line 4 above has been r
48. s that may apply to you See Exempt payee code and Exemption from FATCA reporting code on page 3 Page 14 of 27 Form W 9 Rev 8 2013 Exempt payee code Generally individuals including sole proprietors are not exempt from backup withholding Corporations are exempt from backup withholding for certain payments such as interest and dividends Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions Note If you are exempt from backup withholding you should still complete this form to avoid possible erroneous backup withholding The following codes identify payees that are exempt from backup withholding 1 An organization exempt from tax under section 501 a any IRA or a custodial account under section 403 b 7 if the account satisfies the requirements of section 401 f 2 2 The United States or any of its agencies or instrumentalities 3 A state the District of Columbia a possession of the United States or any of their political subdivisions or instrumentalities 4 A foreign government or any of its political subdivisions agencies or instrumentalities 5 A corporation 6 A dealer in securities or commodities required to register in the United States the District of Columbia or a possession of the United States 7 A futures commission merchant registered with the Commodity Futures Trading Commission 8 A real estate invest
49. s up to 5 00 hours per day Rate Type Oto6 6 to 12 12 to 18 18 to 24 24 to 30 30 to 36 36 months School Age months months months months months months to School up to 13 Age birthday Regular 7 70 7 70 7 70 6 88 6 88 6 88 5 78 5 78 Part Time Full Time Rates 11 01 to 17 00 hours per day Rate Type Oto6 6 to 12 12 to 18 18 to 24 24 to 30 30 to 36 36 months School Age months months months months months months to School up to 13 Age birthday Regular 21 70 21 70 21 70 19 38 19 38 19 38 16 28 16 28 Full Time Full Time Rates 17 01 to 23 59 hours per day Rate Type Oto6 6 to 12 12 to 18 18 to 24 24 to 30 30 to 36 36 months School Age months months months months months months to School up to 13 Age birthday Regular 28 00 28 00 28 00 25 00 25 00 25 00 21 00 21 00 ALTERNATIVE CARE Evening Care When 25 or more of the total time that the child is in care is between the hours of 6 p m to 6 a m Weekend Care Care given to a child between the hours of 6 p m Friday and 6 a m Monday Full Time Alternative Rates 5 01 to 11 00 hours per day Rate Type Oto6 6 to 12 12 to 18 18 to 24 24 to 30 30 to 36 36 months School Age months months months months months months to School up to 13 Age birthday Alternative 16 00 16 00 16 00 16 00 16 00 16 00 16 00 16 00 LCHS 4
50. structions on page 3 Sign Signature of Here U S person gt General Instructions Section references are to the Internal Revenue Code unless otherwise noted Future developments The IRS has created a page on IRS gov for information about Form W 9 at www irs gov w9 Information about any future developments affecting Form W 9 such as legislation enacted after we release it will be posted on that page Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number TIN to report for example income paid to you payments made to you in settlement of payment card and third party network transactions real estate transactions mortgage interest you paid acquisition or abandonment of secured property cancellation of debt or contributions you made to an IRA Use Form W 9 only if you are a U S person including a resident alien to provide your correct TIN to the person requesting it the requester and when applicable to 1 Certify that the TIN you are giving is correct or you are waiting for a number to be issued 2 Certify that you are not subject to backup withholding or 3 Claim exemption from backup withholding if you are a U S exempt payee If applicable you are also certifying that as a U S person your allocable share of any partnership income from a U S trade or business is not subject to the Date gt withholding tax
51. tandard collection procedures which may include State Income Tax intercept if your fiscal agreement is inactive Fraudulent billing will be prosecuted 34 Be paid the rates agreed upon in the attached Fiscal Agreement Rate Information Payments are based on the lesser of the authorized or attended hours 35 This agreement may be cancelled without notice by the department if there are child health or safety concerns involving the provider or a resident in the provider s home Provider Rights 1 When a provider contends that the county has not made adequate payment based on program rules for care provided the provider has the right to an informal conference with county staff pursuant to 9 CCR 2503 1 at Section 3 910 D Providers may request a conference in writing within 15 days of the date of the action This request should be addressed to the county director of the county Department of Social Human services responsible for the action Provider may request that State CCCAP staff participate in the conference That participation may be by telephone conference The conference shall be held within two weeks of the date the request for a conference is received by the county The purpose of the conference is limited to discussion about the payments in dispute and the relevant rules regarding payment The final decision of the county shall be mailed to the provider within 15 days of the conference date 2 A provider may requ
52. tion 1446 withholding on your share of partnership income EAR AK Form W 9 Rev 8 2013 Form W 9 Rev 8 2013 In the cases below the following person must give Form W 9 to the partnership for purposes of establishing its U S status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States e In the case of a disregarded entity with a U S owner the U S owner of the disregarded entity and not the entity e In the case of a grantor trust with a U S grantor or other U S owner generally the U S grantor or other U S owner of the grantor trust and not the trust and e In the case of a U S trust other than a grantor trust the U S trust other than a grantor trust and not the beneficiaries of the trust Foreign person If you are a foreign person or the U S branch of a foreign bank that has elected to be treated as a U S person do not use Form W 9 Instead use the appropriate Form W 8 or Form 8233 see Publication 515 Withholding of Tax on Nonresident Aliens and Foreign Entities Nonresident alien who becomes a resident alien Generally only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U S tax on certain types of income However most tax treaties contain a provision known as a saving clause Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of
53. tion to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W 9 a statement that includes the information described above to support that exemption If you are a nonresident alien or a foreign entity give the requester the appropriate completed Form W 8 or Form 8233 What is backup withholding Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments This is called backup withholding Payments that may be subject to backup withholding include interest tax exempt interest dividends broker and barter exchange transactions rents royalties nonemployee pay payments made in settlement of payment card and third party network transactions and certain payments from fishing boat operators Real estate transactions are not subject to backup withholding You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN make the proper certifications and report all your taxable interest and dividends on your tax return Payments you receive will be subject to backup withholding if 1 You do not furnish your TIN to the requester 2 You do not certify your TIN when required see the Part Il instructions on page 3 for details 3 The IRS tells the requester that you furnished an incorrect TIN 4 The IRS tells you that you are subject to backup withholding because you did not
54. to and out of care daily for attendance tracking and payment Missed check in and check out swipes may be updated within nine 9 days of the date of service The Department does not guarantee payment to the Provider if the transaction status on the POS device is pending denied or not authorized or if the attendance is not accurately recorded through the POS device The parent or adult caretaker shall be responsible for payment and the Department shall not be held liable if the child care is not authorized or the parent or adult caretaker does not accurately record attendance through the device Only approved attendance transactions resulting in a daily matched pair of check ins and check outs will be reimbursed by the Department Train all parents and adult caretaker on the use and importance of the POS device Contact the XEROX Provider Helpline at 1 877 779 1932 within two business days if the Point of Service POS terminal stops working for any reason for troubleshooting or repair Ensure updates to the POS device are implemented as required by CDHS or the fiscal agreement will be terminated Follow the instructions included in the POS User Manual If the provider stops caring for children under the Colorado Child Care Assistance Program they shall contact the Xerox Provider Helpline at 1 877 779 1932 to request a self address postage paid return label to assist in returning the POS device If the POS device is not returne
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