EXEMPT CHILD CARE PROVIDER INFORMATION
Contents
1. 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 line Limited liability company LLC Check the Limited liability company box only and enter the appropriate code for the tax classification D for disregarded entity C for corporation P for partnership in the space provided For a single member LLC including a foreign LLC with a domestic owner that is disregarded as an entity separate from its owner under Regulations section 301 7701 3 enter the owner s name on the Name line Enter the LLC s name on the Business name line For an LLC classified as a partnership or a corporation enter the LLC s name on the Name line and any business trade or DBA name on the Business name line Other entities Enter your business name as shown on required 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 line Note You are requested to check the appropriate box for your status individual sole proprieto2. hereinafter Equipment for use by child care providers and caretakers who qualify for child care benefits Article 1 STATE AND VENDOR RESPONSIBILITIES 1 1 ACS will furnish a Provider with Point of Service POS Equipment and related services installation instructions user manual repair or replacement of Equipment and help desk support for Equipment troubleshooting 1 2 Equipment Equipment shall be a VeriFone model OMNI Vx510 or equivalent if this model becomes obsolete during the term of this agreement 1 3 Equipment Ownership Equipment shall at all times remain the property of the Colorado Department of Human Services 1 4 Equipment Usage Unless otherwise provided for in this Agreement Equipment shall be used by Provider solely in connection with the Colorado Child Care Assistance Program hereinafter CCCAP 1 5 Equipment Allocation One 1 unit of Equipment shall be furnished for every authorized child care provider under the CCCAP Program Additional Equipment may be installed if authorized by CDHS in accordance with the issuance guidelines based on a written request from the provider including the completed additional POS device questionnaire 1 6 Installation Providers must perform the Equipment installation in accordance with the POS Set up Instructions and POS Operations Manual that are included with the Equipment 1 7 Training Providers will be required to attend a training session held by the County or Re
3. see Exempt Payee on page 2 Signature requirements Complete the certification as indicated in 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 Form W 9 Rev 10 2007 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 for rents royalties goods other than bills for merchandise medical and health care services including payments to corporations payments to a nonemployee for services 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 a
4. Bureau of Investigation and or Federal Bureau of Investigation 3 Reimburse the exempt provider for authorized child care in accordance with Colorado Child Care Assistance Program rules Payment to the exempt provider is the total cost of authorized care based on rates set by this Agreement minus the parental fee 4 Determine client s eligibility for child care services within 30 days of the application date 5 Send notices to the exempt provider of changes in parental fees authorized amount of care added or deleted children and other changes to child care arrangements 6 Send Child Care Certificates to the exempt provider within 7 working days of the Department s initial approval or prior to making any changes in eligibility of each child 7 Provide an informal conference within 2 weeks of the exempt provider s written request to discuss the basis for any denial or termination of this agreement or to discuss any payment dispute 8 Provide a written notice of the results of the informal conference within 15 days of the conference date Either party may terminate this Agreement by giving the other party 15 days notice by registered mail This Agreement may be terminated without advance notice if a child s health or safety is endangered The exempt provider may request an informal conference to discuss the basis of any termination or denial of this agreement by submitting that request in writing with 15 days of the action By signing
5. 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 exception to claim an exemption from tax on his or he
6. Trade Commission at soam uce gov or contact them at www consumer gov idtheft or 1 877 IDTHEFT 438 4338 Visit the IRS website at www irs gov 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 who must file information returns with the IRS to report interest dividends and certain other income paid to you mortgage interest you paid the acquisition or abandonment of secured property cancellation of debt or contributions you made to an IRA or Archer MSA or HSA The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return The IRS may also provide this information to the Department of Justice for civil and criminal litigation and to cities states the District of Columbia and U S possessions to carry out their tax laws We may also disclose this information to other countries under a tax treaty to federal and state agencies to enforce federal nontax 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 Payers must generally withhold 28 of taxable interest dividend and certain other payments to a payee who does not give a TIN to a payer Certain penalties may also apply Colorado Department of Human Services Division of Child Care EXEMPT FAMILY CHILD CA
7. completed by the applicant and spouse significant other Self Assurance Form This form requires the client parent of child signature also E E E E E E E E E Copy of Driver s License or government issued ID with current 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 Point of Service POS Device Provider Agreement 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 re ee DEPARTMENT OF HUMAN SERVICES adie Child Care Assistance Program LCHS 4226 07 10 970 498 6300 Fax 970 498 7987 MORE INFORMATION ON BACK Please note If you are approved as a legally exempt child care 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 dependant upon the final outcome of the background check
8. how will bill for care that provide understand that the POS will send billing to the Department on a weekly basis for payment will notify the Department immediately if the POS system is not working correctly so it may be repaired will maintain an analog land line for phone service to ensure that the POS terminal can submit attendance information to the county for payment on a weekly basis may manually bill the Department for services authorized based on county payroll policies that are not reimbursable automatically based on the POS transactions forfeit payment for services if the original manual billing form is submitted more than sixty 60 calendar days following the weekly service period When the adult caretaker swipes their card into the POS and the terminal indicates the status of pending or not authorized there is no guarantee of payment to the exempt provider from the Department If the child care case is not authorized then responsibility for payment lies with the parent and the Department shall not be held liable For payment the adult caretaker shall swipe their card at the provider s location to sign in and out each day Missed swipes may be updated within ten days of the date of service will never keep in my possession whether at the facility or in any other place a client s Child Care Benefits Card used to swipe for attendance Possession of any swipe card s will terminate this fisca
9. 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 the instructions below and the separate Instructions for the Requester of Form W 9 Also see Special rules for partnerships on page 1 Penalties Failure to furnish 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
10. 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 Child Care Accounting Larimer County DHS 2601 Midpoint Drive Suite 112 Fort Collins Colorado 80525 Rev 04 30 2004 W 9 Form Rev October 2007 Department of the Treasury Internal Revenue Service Request for Taxpayer 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 if different from above Check appropriate box Individual Sole proprietor C Other see instructions gt Addres
11. ADDITIONAL INFORMATION After the requested paperwork is received listed on the front 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 over the age of 18 The table below indicates fees charged by the Colorado 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 Cost Number Total Needed Cost Administration fee for the provider packet 10 00 1 10 00 Fee for each set of fingerprints submitted to the Colorado Bureau of 17 50 Investigation Fee for each set of fingerprints submitted to the Colorado Bureau of Investigation and the Federal Bureau of Investigation If Colorado has 39 50 been your state of residence for less than two 2 consecutive years In addition a 20 00 fee will be charged at the time of service by the Larimer County s Sheriffs Department for each set of fingerprints needed LARIMER COUNTY DEPARTMENT OF HUMAN SERVICES Child Care Assistance Program LCHS 4226 07 10 a 970 498 6300 Fax 970 498 7987 Exempt Family Child Care Home Provider Fiscal Agreement License Certificate No Tax ID No This Agreement is entered into and between the Larimer County Depart
12. ARIMER DEPARTMENT OF HUMAN SERVICES COUNTY Child Care Assistance Program 970 498 6300 Fax 498 7987 COMMITTED TO EXCELLENCE 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 your existing card PLEASE SELECT ONLY ONE OF THE FOLLOWING CHOICES QO 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 COL
13. CARE PROVIDER By n Signature Signature Name type or print Name type or print Title Title Date Date o Please return this complete Provider Agreement to the County ACS cannot ship Equipment until the signed Agreement is returned LCHS 5565 07 10 State of Colorado Provider Agreement P age 4of5 EXHIBIT A PROVIDER LOCATION INFORMATION Provider ID Number Tax ID Number TIN The following are the Provider locations authorized by the State of Colorado s Child Care Automated Attendance Program Copy this page if more locations need to be listed Facility Number 1 2 3 4 Facility Name Street Address City State and Zip Primary phone Secondary phone Fax number E mail address Emergency phone Primary Point of Contact Secondary Point of Contact Check here if additional sheets are attached listing more locations This is sheet of total Please return this complete Provider Agreement to the County ACS cannot ship Equipment until the signed Agreement is returned LCHS 5565 07 10 State of Colorado Provider Agreement Page 5of5
14. EXEMPT CHILD CARE PROVIDER INFORMATION Thank you for your interest in becoming a legally exempt child care provider for the Larimer County Child Care Assistance Program CCAP Due to a change in law we must conduct a fingerprint based criminal check as well as an internal background check on all members of your household that are eighteen years of age and older As a potential legally exempt child care provider for LCDHS there are fees that you will be responsible to pay Please see Additional Information section below regarding fees and instructions It is estimated that this process will take a minimum of two to six months or longer depending on how long you have lived in the State of Colorado Even after the entire process has been completed it is not a guarantee that you will be approved as a legally exempt child care provider To begin this new process the following must be completed and received by the Larimer County Department of Human Services before care begins Payment to a 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 Child Care Services Exempt Provider Fiscal Agreement Child Care Rate Information for Exempt Providers Payment Choice Letter W 9 We only need page 1 back Exempt Family Child Care Home Provider Information Authorization to Supply Information Affidavit of Citizenship To be
15. ORADO 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 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 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 _ _ lt OR SOCIAL SECURITY NUMBER et CHECK HERE IF THIS IS
16. RACTED 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 1 00 o m Fort Collins CO 80525 Wendy 00 p 970 498 6366 LCHS 5566 01 11 COLORADO CHILD CARE AUTOMATED TRACKING SYSTEM POINT OF SERVICE POS DEVICE PROVIDER AGREEMENT Provider ID No Effective Date This Agreement is made by and between the Colorado Department of Human Services or our agent County Name hereinafter CDHS and Provider Name a n individual s LIpartnership Icorporation other hereinafter Provider organized and existing under the Laws of the State of Colorado and having a business or home located at the address of ACS State and Local Solutions hereinafter ACS is under contract with the Colorado Department of Human Services through their contract with Deloitte Consulting LLC to provide an automated child care system that provides timekeeping and recording of attendance for authorized child care attendees As part of that contract ACS is the custodian responsible to furnish and maintain equipment
17. RE HOME PROVIDER INFORMATION Please Print Legibly All sections of this form must be completed in order to avoid delays in processing Provider Name Legal Last Name Legal First Middle Mailing Address Street Address PO Box City State Zip Date of Birth poh Soc Sec Previous Name s Home phone Work Cell Have you had legal residence in any state other than Colorado over the past two years OYes UNo If yes list other states and dates of residence Race OAsian OBlack African American OAmerican Indian Alaskan Native OHispanic ONative Hawaiian Other Pacific Islander OCaucasian Signature Date Please list all persons in your home Include all relatives non relatives and temporary residents Use an additional form if needed You will need to complete a new EXEMPT CHILD CARE PROVIDER INFORMATION FORM any time a new person moves into your home or if you have a child who turns 18 during your contract period You and each adult 18 years of age or older who resides in your home 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 1 Previous Name s Legal Last Name Legal First Middle Date of Birth Age Relationship to provider Soc Sec Race QOAsian OBlack African American OAmerican Indian Alask
18. a partner is a foreign person and pay the 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 withholding on your share of partnership income The person who gives 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 is in the following cases e The U S owner of a disregarded entity and not the entity Form W 9 Rev 10 2007 Form W 9 Rev 10 2007 e The U S grantor or other owner of a grantor trust and not the trust and e The U S trust other than a grantor trust and not the beneficiaries of the trust Foreign person If you are a foreign person do not use Form W 9 Instead use the appropriate Form W 8 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 income even after the payee has otherwise become a U
19. an Native OHispanic ONative Hawaiian Other Pacific Islander OCaucasian Have you had legal residence in any state other than Colorado over the past two years OYes UNo If yes list other states and dates of residence Signature Date 2 Previous Name s Legal Last Name Legal First Middle Date of Birth Age Relationship to provider Soc Sec Race QOAsian OBlack African American OAmerican Indian Alaskan Native OHispanic ONative Hawaiian Other Pacific Islander OCaucasian Have you had legal residence in any state other than Colorado over the past two years OYes UNo If yes list other states and dates of residence Signature Date 3 Previous Name s Legal Last Name Legal First Middle Date of Birth Age Relationship to provider Soc Sec Race OAsian OBlack African American OAmerican Indian Alaskan Native OHispanic ONative Hawaiian Other Pacific Islander OCaucasian Have you had legal residence in any state other than Colorado over the past two years OYes UNo If yes list other states and dates of residence Signature Date 4 Previous Name s Legal Last Name Legal First Middle Date of Birth Age Relationship to provider Soc Sec Race QOAsian OBlack African American OAmerican Indian Alaskan Native OHispanic ONative Hawaiian Other Pacific Islander UOCaucasian Have you had legal residence in any state other than Colorado over the past two years OYes UONo If yes list other states and d
20. ates of residence Signature Date LCHS 4286 12 08 Exempt Form 1 06 06 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 Exempt 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 household member understand based on the information received my local county department of social numan 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 Exempt Child Care understand this authorization shall continue in force unless rescinded earlier by me in writing Provider s Signature Date STATEMENT OF CRIMINAL HISTORY 1 Has any member of your household been arrested or convicted of a crime Yes No If yes give name and please explain 2 Has any member of your household been investigated charged with or convicted of child abuse neglect or child molest
21. ation Yes NoU If yes give name and please explain certify that the information that 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 an exempt family child care home provider 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 Provider s Signature Date Exempt Form 1 pg 2 LCHS 4287 09 08 AFFIDAVIT for the Colorado Department of Human Services as Proof of Lawful Presence in the United States swear or affirm under penalty of perjury under the laws of the State of Colorado that check one I am 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 affi
22. bandonment 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 What Name and Number To Give the Requester For this type of account Give name and SSN of 1 Individual 2 Two or more individuals joint account 3 Custodian account of a minor The individual The actual owner of the account or if combined funds the first individual on the account aa The minor Uniform Gift to Minors Act 4 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 5 Sole proprietorship or disregarded The owner entity owned by an individual The grantor trustee i The actual owner For this type of account Give name and EIN of 6 Disregarded entity not owned by an The owner individual 7 A valid trust estate or pension trust 8 Corporate or LLC electing corporate status on Form 8832 9 Association club religious charitable educational or other tax exempt organization 10 Partnership or multi member LLC 11 A broker or registered nominee 12 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 agricul
23. davit 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 AFFIDAVIT for the Colorado Department of Human Services as Proof of Lawful Presence in the United States swear or affirm under penalty of perjury under the laws of the State of Colorado that check one I am 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 b
24. enefit 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 SS 31 Rev 3 2010 Technician Coach COLORADO DEPARTMENT OF HUMAN SERVICES CHILD CARE STANDARDS FOR EXEMPT PROVIDERS SELF ASSURANCE FORM Provider Name Provider Care will be provided by O Relative Where will care be done In O Providers Home OTR or O Child s Home INR Care will be provided by O Non Relative Where will care be done In O Provider s Home OTN or O Child s Home INN Please answer each of the following questions by placing an X in 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 you or any resident of your home ever been convicted of admitted to or had substantial evidence of an act of child battering child abuse child molesting and child neglect 3 Have you or any resident of your home ever been convicted of a felony 4 Have any of your own children ever been placed in foster care or a residential treatment facility 5 Are you at least 18 years of age Date of Birth 6 Do you have adequate physical stamina and mental capacity to meet the needs of the children 7 Are you free of other responsibilities and demands
25. ent be liable for any damages including but not limited to special consequential or exemplary damages of any kind whether arising in contract tort warranty indemnification or contribution or under any other theory of law with regard to matters arising from this Agreement INDEMNIFICATION Except for CDHS or ACS gross negligence if any claim is asserted or action brought against CDHS or ACS arising from this Agreement Provider shall hold harmless and defend CDHS and or ACS from any such claim or action at Provider expense and shall indemnify CDHS and or ACS for any cost and damages including attorney s fees actually incurred by CDHS and or ACS in connection therewith WARRANTIES ACS WARRANTS THAT SERVICES PROVIDED UNDER THIS AGREEMENT WILL BE PERFORMED IN ACCORDANCE WITH INDUSTRY STANDARDS BY QUALIFIED PERSONNEL IN A QUALITY MANNER AND WILL CONFORM TO THE SPECIFICATIONS AS DESCRIBED HEREIN THE EXPRESS WARRANTIES SET FORTH IN THIS SECTION ARE THE ONLY WARRANTIES GIVEN BY ACS WITH RESPECT TO THE SERVICES AND EQUIPMENT PROVIDED PURSUANT TO THIS AGREEMENT ACS MAKES NO OTHER WARRANTIES EXPRESSED OR IMPLIED OR ARISING BY CUSTOM OR TRADE USAGE AND SPECIFICALLY MAKES NO WARRANTY OF MERCHANTABILITY OR FITNESS FOR ANY PARTICULAR PURPOSE GOVERNING LAW This Agreement will be governed by and construed in accordance with the Laws of the State of Colorado and any action commenced hereunder shall be brought in State of Colorado Further Pro
26. f Columbia or a possession of the United States 9 A futures commission merchant registered with the Commodity Futures Trading Commission 10 A real estate investment trust 11 An entity registered at all times during the tax year under the Investment Company Act of 1940 12 A common trust fund operated by a bank under section 584 a 13 A financial institution 14 A middleman known in the investment community as a nominee or custodian or 15 A trust exempt from tax under section 664 or described in section 4947 The chart below shows types of payments that may be exempt from backup withholding The chart applies to the exempt payees listed above 1 through 15 IF the payment is for THEN the payment is exempt for Interest and dividend payments All exempt payees except for 9 Broker transactions Exempt payees 1 through 13 Also a person registered under the Investment Advisers Act of 1940 who regularly acts as a broker Barter exchange transactions and patronage dividends Exempt payees 1 through 5 Payments over 600 required to be reported and direct sales over 5 000 Generally exempt payees 1 through 7 See Form 1099 MISC Miscellaneous Income and its instructions However the following payments made to a corporation including gross proceeds paid to an attorney under section 6045 f even if the attorney is a corporation and reportable on Form 1099 MISC are not exemp
27. gin age sex religion or physical or mental handicap will provide children with adequate food shelter and rest will provide care for children under this agreement only if authorized by the Department in advance 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 will maintain as strictly confidential all information concerning children and their families will protect children from abuse neglect and report any suspected child abuse and neglect to the Department will hold the Colorado Department of Human Services the State of Colorado and the County Department of Social Services harmless for any loss or actions caused by the performance of this Agreement agree that allowable rates and other associated charges shall be in accordance with State Rules for Colorado Child Care Assistance Program and in accordance with Larimer County policies understand that if commit fraud or intentional program violations 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 shall charge the Department the county rates of reimbursement as set forth in the attached document To manually bill for claims as needed the provider will need to maintain sign in o
28. l agreement and preclude the exempt provider from providing child care assistance services in the future with any county If stop caring for children under the Colorado Child Care Assistance Program a self addressed postage paid return label will be mailed to the provider to assist in returning the POS device If the POS device is not returned in good shape allowing for normal wear and tear to Affiliated Computer Systems ACS a recovery will be established for the cost of replacement for the POS device of 365 will report non payment of parent fees no later than the end of the month they have not been received I understand that the Department cannot enforce non payment of parent fees if this information is not reported will notify the Department of unexplained frequent and or consistent absences within ten 10 calendar days of establishing a pattern LCHS 4297 03 10 SS 67 E R 03 10 Exempt Provider Form 3 19 20 21 22 23 24 25 26 27 28 29 30 31 will not charge parents rates in excess of those agreed upon in the fiscal agreement and on the most recent child care certificate this includes the agreed upon registration mandatory activity and transportation fees if the county pays these fees will allow the adult caretaker immediate access to the child in care will accept referrals for child care without discrimination with regard to race color national ori
29. lternative 6 p m to 6 a m 18 months 16 00 day 9 50 day 32 00 day 19 00 day Weekend Care Care given to children between the hours of 6 p m Friday and 6 a m Monday Evening Care When 25 or more of the total time that the children are in care is between the hours of 18 months Alternative 6 p m to 6 a m to 16 00 day 9 50 day 32 00 day 19 00 day Weekend Care Care given to children between the hours 3 years of 6 p m Friday and 6 a m Monday Evening Care When 25 or more of the total time that the children are in care is between the hours of 3 Alternative 6 p m to 6 a m years up 1o 16 00 day 9 50 day 32 00 day 19 00 day Weekend Care Care given to children between the hours of 6 p m Friday and 6 a m Monday 13 birthday 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 schedule for Larimer County Provider Signature LCHS 4233 03 10 Date White Acct file Yellow Provider Provider ID LARIMER N COUNTY rra DEPARTMENT OF HUMAN SERVICES Child Care Assistance Program 970 498 6300 Fax 970 498 7987 L
30. ment of Human Services herein referred to as Department and herein referred to as provider who will provide child care at the following address This agreement shall be in effect from to Exempt Provider Agrees to the following 1 OS O OND 10 12 To 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 home for the same purpose The County is not responsible for payment of any child care that the provider has provided while the fiscal agreement is under screening and background check To provide verification of Lawful Presence in the United States and provide an affidavit of citizenship To notify the Department within ten calendar days of any circumstances that results in the presence of a new adult age 18 and over in the residence To provide child care at the facility address listed above To report any changes in my phone number or address to the county within ten days of the date it changes To conform to all applicable State and Federal Regulations and local law To sign the child care fiscal agreement and all other county or state required forms To develop an individualized care plan for disabled children understand that must attend training before will receive a Point Of Service POS device The POS device is
31. n 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 Exempt Day Care Home There is no limit to the number of children in care for exempt day care homes that meet the following criteria e relative provider cares for 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 e non relative provider cares for children from one family household In addition the provider may care for any children for whom they are the legal guardian or parent SIGNATURES REQUIRED ON BACK PAGE 2 LCHS 4263 04 10 Page 1 F SELF ATTESTATION I attest that no one in my household has been determined to be insane or mentally incompetent by a court of competent jurisdiction and that no court has entered an order specifically finding that anyone s mental incompetence or insanity is of such a degree that I cannot safely operate an Exempt Family Child Care Home G REMARKS If you cannot agree to all of these assurances those not agreed to must be verified by the County Department from county records and may result in non approval Provider signature Date NON LICENSED PROVIDERS STATUS By signing below I state that I have reviewed the assurances above and understand the following statements This provider is not required by Colo
32. ng a tax preparer Call the IRS at 1 800 829 1040 if you think your identity has been used inappropriately for tax purposes 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 personal property to the Treasury Inspector General for Tax Administration at 1 800 366 4484 You can forward suspicious emails to the Federal
33. nt director of the county department of social numan services responsible for the action e Exempt providers may request that state program staff participate in the conference That participation may be by telephone conference e The purpose of the conference will be limited to discussion of the payments in dispute and the relevant rules regarding payment An exempt provider may request an informal conference if s he disputes the termination of a fiscal agreement e Exempt providers may request a conference in writing within 15 days of the dates of the date of the action e Exempt provider requests should be addressed to the Department director of the county department of social numan services responsible for the action LCHS 4297 03 10 SS 67 E R 03 10 Exempt Provider Form 3 e The purpose of the conference will be limited to discussion to termination of agreement pursuant to 9 CCR 2503 1 at Social Services Staff Manual Department Agrees to 1 Exercise its option to reimburse the exempt child care provider for care from the date the completed fingerprint packet and fees for the provider s households are received by the Division of Child Care The exempt provider may continue to receive moneys after that as long as the exempt provider and all qualified adults living in the residence show no evidence of criminal offenses or a pattern of misdemeanor offenses 2 Exercise its option to pay after the results are returned from the Colorado
34. ployer 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 www 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 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 domestic entity that has a foreign owner must use the appropriate Form W 8 Part Il Certification To establish to the withholding 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 and 5 below indicate otherwise For a joint account only the person whose TIN is shown in Part should sign when required Exempt payees
35. pment Return Provider agrees that it shall return the Equipment to ACS if the Equipment is defective non operable or if the Provider is no longer caring for CCAP children TERM AND TERMINATION Term The term of the Agreement shall commence on the Effective Date and extend for as long as the provider cares for CCCAP children hereinafter Initial Term Termination Either party may terminate this Agreement without cause upon giving fifteen 15 days prior written notice to the other party citing Section 3 4 This Agreement shall terminate immediately upon the rendering of a negative licensing decision or confirmation of a health and safety issue Effect of Termination Equipment Upon termination the provider will receive a pre paid pre addressed mailing label and will ship all Equipment components including power pack to the ACS Depot within five 5 business days If all Equipment is not returned CDHS will establish a recovery for the cost of replacement of the Equipment LCHS 5565 07 10 State of Colorado Provider Agreement Page2of5 Article 4 4 1 Article 5 5 1 Article 6 6 1 Article 7 7 1 7 2 Article 8 8 1 Article 9 9 1 Article 10 10 1 LOSS OF EQUIPMENT Provider agrees to bear the expenses to replace Equipment that is lost suffers a casualty loss or is stolen while the Equipment is in the Provider s care LIMITATION OF LIABILITY Neither CDHS nor ACS shall in any ev
36. r corporation etc Exempt Payee If you are exempt from backup withholding enter your name as described above and check the appropriate box for your status then check the Exempt payee box in the line following the business name sign and date the form Form W 9 Rev 10 2007 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 Note If you are exempt from backup withholding you should still complete this form to avoid possible erroneous backup withholding The following payees 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 or 5 An international organization or any of its agencies or instrumentalities Other payees that may be exempt from backup withholding include 6 A corporation 7 A foreign central bank of issue 8 A dealer in securities or commodities required to register in the United States the District o
37. r 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 not subject to backup withholding give the requester the appropriate completed Form W 8 What is backup withholding Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28 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 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 II instructions on page 3 for details 3 The IRS tells the requester that you furnished an incorrect TIN Page 2 4 The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return for reportable interest and dividends only
38. rado law to obtain a child care license or meet monitoring requirements for licensed providers 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 Signature Date REVIEW OF FORM County Representative Date LCHS 4263 04 10 Page 2 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 Exempt 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 CONT
39. s number street and apt or suite no Corporation Limited liability company Enter the tax classification D disregarded entity C corporation P partnership _ payee Partnership Exempt Requester s name and address optional City state and ZIP code List account number s here optional Print or type See Specific Instructions on page 2 Part 1 Taxpayer Identification Number TIN Enter your TIN in the appropriate box The TIN provided must match the name given on Line 1 to avoid backup withholding For individuals this is your social security number SSN However for a resident i 1 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 or Note If the account is in more than one name see the chart on page 4 for guidelines on whose number to enter Social security number 1 1 l 1 Employer identification number Gena 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 subjec
40. source and Referral Agency prior to receiving a POS Device Providers will receive additional training by reading the Quick Reference Guide and POS Operations Manual These materials will be included with the Equipment 1 8 Help Desk ACS shall provide help desk assistance for Provider use 24 hours per day 7 days per week with automated troubleshooting tips The Help Desk can be reached at 1 877 779 1932 starting on June 7 2010 The Help Desk will provide Customer Service Agent assistance from 7 am to 7 pm Mountain time Help Desk services are available in both English and Spanish Assistance is limited to Equipment problems only 1 9 Equipment Repair ACS shall be solely responsible for repair of Equipment For Equipment repair Provider shall promptly notify ACS using the Help Desk The Help Desk can be reached at 1 877 779 1932 starting on June 7 2010 Repair calls are processed through the LCHS 5565 07 10 State of Colorado Provider Agreement Page1of5 Article 2 2 1 2 2 2 3 2 4 2 5 2 7 2 8 Article 3 3 1 3 2 3 4 Help Desk At ACS discretion Equipment may be repaired or replaced If Equipment must be replaced a replacement device will be shipped within two days to the Providers place of business along with a self addressed postage paid return label so the defective device can be returned to ACS PROVIDER RESPONSIBILITIES Equipment Use and Care The Provider agrees that it shall follow the instruc
41. t from backup withholding medical and health care payments attorneys fees and payments for services paid by a federal executive agency Page 3 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 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 Em
42. t 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 Iam a U S citizen or other U S person defined below 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 instructions on page 4 Sign Signature of Here U S person gt General Instructions Section references are to the Internal Revenue Code unless otherwise noted 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 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 req
43. that would interfere with the provision of care individual attention and nurturing for the children in care 8 Are you experienced in the care of children knowledgeable of their needs and development and able to deal effectively with problems emergencies and discipline 9 Are you able to work cooperatively with the parents and agency in providing appropriate discipline care and direction for the children that will not be in conflict with parental practices 10 Are you willing to participate in training programs B HOUSE AND YARD Yes No 1 Is your house and yard maintained free from hazards to health and safety C EQUIPMENT Yes No 1 Do you have materials and equipment appropriate for the age of children in care and in good repair that will be available for both active and quiet play D FEEDING AND HEALTH CARE OF THE CHILDREN Yes No 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 CHILDREN IN CARE Yes No 1 Will you provide child care that complies with the following standards for child care facilities exempt from Colorado licensing laws a Child s Own Home When children are i
44. this agreement the exempt provider acknowledges receipt of information regarding the rules and policies of the Colorado Child Care Assistance Program Violation of the terms of this agreement may be determined a violation of the Colorado Child Care Assistance Program Colorado Child Care Assistance Program CHILD CARE EXEMPT PROVIDER DEPARTMENT OF HUMAN SERVICES Marsha Ellis Print Name Print Name Signature Signature 1501 Blue Spruce Drive Mailing Address Address Fort Collins Colorado 80524 498 6300 City State Zip Phone Number City State Zip Phone Number LCHS 4297 03 10 SS 67 E R 03 10 Exempt Provider Form 3 EXEMPT PROVIDERS CHILD CARE CONTRACT ADDENDUM Rate Information Effective June 7 2010 RATE TYPE DEFINITION CHILD S FULL TIME PART TIME DISABILITY DISABILITY AGE MAXIMUM MAXIMUM FULL TIME PART TIME GROUP 5 Hours or Less than 5 MAXIMUM MAXIMUM More Hours g 3 Birth up to Basic Care during standard business hours 6 a m to 6 p m 13 months 14 00 day 9 00 day 28 00 day 18 00 day 18 months Basic Care during standard business hours 6 a m to 6 p m to 12 50 day 8 00 day 25 00 day 16 00 day 3 years x 3 3 years up to Basic Care during standard business hours 6 a m to 6 p m 13 birthday 10 50 day 6 50 day 21 00 day 13 00 day Evening Care When 25 or more of the total time that the children are in care is between the hours of Birth up to A
45. tions of any manuals accompanying the Equipment as amended from time to time in the care use and installation requirements of the Equipment as specified by the manufacturer Equipment Security Provider agrees that it shall provide reasonable security measures to protect the Equipment from damage theft or unauthorized use Equipment Environment Provider agrees that it shall provide a three pronged electric outlet to operate the Equipment a place for Equipment installation that is easily accessible to clients and safe from damage an analog land line for phone service for use by the Equipment shared or dedicated at Provider discretion Provider agrees to be solely responsible for and bear all one time and recurring expenses and fees related to the operation of the Equipment e g electrical telephone etc Equipment Control and Location Provider agrees that it will at all times keep the Equipment in its sole possession and control The Equipment shall not be moved from the Provider address es stated in Exhibit A without prior written notification to CDHS and ACS Provider agrees that at all times it shall provide accurate and current data for Exhibit A Equipment Repair Provider agrees that it shall not make or attempt to make any repairs to the Equipment Equipment Supplies Provider agrees that it shall be responsible for procuring the Equipment s thermal printer paper Thermal paper can be purchased at office supply stores Equi
46. tural program payments Legal entity i The corporation The organization The partnership The broker or nominee The public entity List first and circle the name of the person whose number you furnish If only one person on a 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 second name line You may use either your SSN or EIN if you have one but the IRS encourages you to use your SSN 4 List first and circle 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 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 Page 4 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 Protect your SSN e Ensure your employer is protecting your SSN and e Be careful when choosi
47. uesting 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 withholding tax on foreign partners share of effectively connected income Note If 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 Cat No 10231X Date gt Definition of a U S person For federal tax purposes you are considered a U S person if you are An individual who is a U S citizen or U S resident alien 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 on any foreign partners share of income from such business Further in certain cases where a Form W 9 has not been received a partnership is required to presume that
48. ut sheets with the time the children arrive and leave each day they attend This record must be signed by the person authorized to drop off or pick up the child ren You must submit sign in out sheet for each child in your care for all MANUAL bill claims or the payment cannot be processed These records must be available for county review upon request and maintained for the current year plus three years To provide child care at the address listed above and ensure that care is provided only by the person listed above understand that payment made for inaccurate or fraudulent billings will be recovered Fraudulent billing will be prosecuted 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 If your fiscal agreement is inactive Larimer County shall collect the overpayment in accordance with the standard collection procedures Exempt provider Rights 1 When an exempt provider contends that the Department has not made adequate payment based on pogram rules for care provided the exempt provider has the naht to an informal conference with epartment staff pursuant to 9 CCR 2503 1 at Section 3 910 D e Exempt providers may request a conference in writing within 15 days of the date of the action e Exempt provider requests should be addressed to the Departme
49. vider consents to the jurisdiction of the courts located in State of Colorado ASSIGNMENT Neither this Agreement nor any right or obligation hereunder shall be assigned to third parties by the Provider without the prior written consent of CDHS and ACS AMENDMENTS OR EXHIBITS The amendments or exhibits listed below are incorporated herein by reference Exhibit A Provider Location Information LCHS 5565 07 10 State of Colorado Provider Agreement P age 3of5 Article 11 INDEPENDENT CONTRACTOR 11 1 The parties shall at all times be independent contractors and nothing contained herein shall be deemed to create any association partnership joint venture or relationship of principal and agent or employer and employee between the parties Article 12 ENTIRE AGREEMENT AND MODIFICATIONS 12 1 This Agreement supersedes any and all prior representations conditions warranties understandings proposals or previous agreements between the parties hereto either oral or written relating to the matters of this Agreement hereunder and constitutes the sole full and complete agreement between the parties 12 2 Further this Agreement shall not be modified changed amended or waived except by means of a written instrument signed by an authorized representative of each party IN WITNESS WHEREOF the parties hereto have through duly authorized officials executed this Agreement COLORADO DEPARTMENT OF HUMAN SERVICES OR OUR AGENT CHILD
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