Microsoft Word - PPA-English 2019

Care 4 Kids PPA (rev. 7/2019) Page 1 of 5

Parent Name: C4K Case Number:

Si quiere recibir este formulario en español, llame al 1-888-214-5437.

Step 1: This form must be completed by the parent and the child care provider.

 Parent – Complete Sections 1, 3 and 5.

 Child Care Provider – Complete Sections 2, 3 and 4.

Step 2: Make sure all sections have been filled in and the information is correct. Answer all Yes or No questions by checking the

right box. Once you have filled out and checked this form, make sure the parent and provider sign and date this form. If

you need help, call 1-888-214-5437 or visit www.ctcare4kids.com. Incomplete forms may not be accepted and will delay

processing.

Step 3: The law requires us to report all payments to the Internal Revenue Service (IRS) for income tax purposes. If you are a new

child care provider with Care 4 Kids (C4K), you must provide us with your Social Security Number or Federal Employer

Identification Number and fill out an IRS W-9 form. To get a W-9 form by mail, call 1-888-214-5437, or download the form

at www.ctcare4kids.com. If you have already submitted a W-9 form to us, you do not need to fill out a new form unless

your information has changed. Care 4 Kids does not withhold income taxes. Providers are responsible for paying taxes to

the IRS and the State of Connecticut.

Step 4: Submit the filled out form to: Care 4 Kids, 1344 Silas Deane Highway, Rocky Hill, CT 06067 or fax it to: 1-877-868-0871.

SECTION 1: PARENT INFORMATION (To be comp leted by Parent)

Parent Name: C4K Case Number:

Last Name, First Name, Middle Initial

Parent Address: City, State, Zip Code:

Telephone Number: (Primary) (Secondary)

Reason for submitting this form:  Part of my Application or Redetermination  Reporting changes or a new provider

SECTION 2: CHILD CARE PROVIDER INFORMATION (To be c omp lete d by Provider)

What type of child care provider are you? Are you accredited by any of the following? (check if yes)

 Unlicensed Individual (relative)  National Assoc. for the Education of Young Children (NAEYC)

 Licensed Family Child Care Home  Council on Accreditation (COA)

 Licensed Child Care Center  New England Assoc. of Schools and Colleges (NEASC)

 Licensed Group Child Care Home  National Assoc. for Family Child Care (NAFCC)

 Licensed Youth Camp

 Exempt Youth Camp

 Exempt Center Based Program

SECTION 2A: LICENSED CHILD CARE PROVIDERS/EXEMPT PROGRAMS (To be completed b y

Prov ider)

PROVIDER NAME

Center Name: Licensed Home:

(Last) (First)

Address where child care is provided:

Street City State Zip Code

Telephone Number: ( )___________________________

Date of Birth: C4K Provider ID: License Number:

Family Home Providers Only

Family Home Providers Only:  I understand I must complete the pre-service training requirement prior to becoming eligible for

payment. For more information, visit www.ctcare4kids.com.

Please list the address you would like notices to be mailed if different from the address where child care is provided:

Street Address: City, State, Zip Code:

Paren

Provider Agreement Form

This form tells us about the child care arrangement.

Care 4 Kids PPA (rev. 7/2019) Page 2 of 5

Parent Name: C4K Case Number:

SECTION 2B: UNLICENSED RELATIVE CHILD CARE PROVIDERS (To be c omp lete d by Pro vider)

You must be related to the child by blood, marriage, or adoption. This means the child is your grandchild, great grandchild, niece,

nephew, or sibling. If you are not related, you must have a license from the Office of Early Childhood Division of Licensing to provide

child care.

Provider Name:

Last Name, First Name, Middle Initial

Home Address: City, State, Zip Code:

Telephone Number: C4K Provider ID:

Date of Birth: / / Gender:  Male  Female

 I understand I must complete the pre-service training requirement prior to becoming eligible for payment. For more

information, visit www.ctcare4kids.com.

Are you self-employed or do you have another job?  YES  NO If yes, list your work schedule at your other job in the table below.

Name, Address, and Telephone Number of your other job:

Providers: Use this table to list the hours and days you normally work your other job (circle AM or PM).

TIME SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

Start

______:______ PM

End

______:______ PM

Where do you provide child care for the children listed on this agreement form?  Child’s home  Provider’s home Other

Is there a working telephone at this care location?  YES  NO Telephone number: ( )_________________________

Is there a working smoke detector?  YES  NO Do you have immediate access to a fire extinguisher?  YES  NO

What is the total number of children in your care at the same time on any day, including your own children?

How many of these children are under the age of 2, including your own children?

Are you under investigation by the Department of Children and Families (DCF) for child abuse or child neglect or do you have a

record of child abuse or child neglect in Connecticut or any other state?  YES  NO

Were you ever arrested or do you have an arrest warrant or criminal charge pending against you?  YES  NO

What crime(s) were you charged with? When and where?

Have you ever been convicted of any of the crimes listed below?  YES  NO

 Abandonment, injury or risk of injury to a minor.

 Cruelty to persons or animals, stalking, obscenity, public indecency, reckless endangerment, arson, robbery, burglary,

home invasion.

 Use of force against another person, including murder, assault, manslaughter, kidnapping, unlawful restraint.

 Crimes involving a weapon, explosives, or a firearm.

 Sex crimes including sexual assault, rape, prostitution, child pornography, and other related sex crimes.

 Sale, manufacture, or possession of narcotics or other illegal drugs or controlled substances.

For a complete crime list please visit www.ctcare4kids.com

NOTE: All Unlicensed Relative Providers are subject to child abuse/neglect, sex offender, and criminal background checks. If the results of the

background check confirms you are ineligible, you will be required to repay Care 4 Kids benefits issued to you.

Care 4 Kids PPA (rev. 7/2019) Page 3 of 5

Parent Name: C4K Case Number:

SECTION 3: CHILDREN IN CARE (To be com plete d togeth er by Parent an d Provider)

Complete for each child needing Care 4 Kids assistance. If there are more than 3 children in your care, make a copy of this page or download and

print another copy of this page from the Care 4 Kids website at www.ctcare4kids.com.

CHILD #1

/ /

LAST NAME FIRST NAME M.I. DATE OF BIRTH

Date care started: How much is the parent charged per week? $

Are you charging a mandatory registration fee for this child at this time?  YES  NO If yes, how much is the registration fee? $______________

Are you related to this child?  YES  NO If related, specify your relationship to the child:

 Grandparent/Great Grandparent  Aunt/Uncle  Sibling  Other: ___________________

CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (circle AM or PM)

Day of the Week

Schedule 1 Begin Time Schedule 1 End Time Schedule 2 Begin Time Schedule 2 End Time

Sunday

_____:_____ AM PM _____:_____ AM PM _____:_____ AM PM _____:_____ AM PM

Monday

_____:_____ AM PM

Tuesday

_____:_____ AM PM

Wednesday

_____:_____ AM PM

Thursday

_____:_____ AM PM

Friday

_____:_____ AM PM

Saturday

_____:_____ AM PM

Is this child care schedule the same each week?  YES  NO If no, explain how the care schedule varies:

________________________________________________________________________________________________________________________

CHILD #2

/ /

LAST NAME FIRST NAME M.I. DATE OF BIRTH

Date care started: How much is the parent charged per week? $

Are you charging a mandatory registration fee for this child at this time?  YES  NO If yes, how much is the registration fee? $______________

Are you related to this child?  YES  NO If related, specify your relationship to the child:

 Grandparent/Great Grandparent  Aunt/Uncle  Sibling  Other: ___________________

CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (circle AM or PM)

Day of the Week

Schedule 1 Begin Time Schedule 1 End Time Schedule 2 Begin Time Schedule 2 End Time

Sunday

_____:_____ AM PM _____:_____ AM PM _____:_____ AM PM _____:_____ AM PM

Monday

_____:_____ AM PM

Tuesday

_____:_____ AM PM

Wednesday

_____:_____ AM PM

Thursday

_____:_____ AM PM

Friday

_____:_____ AM PM

Saturday

_____:_____ AM PM

Is this child care schedule the same each week?  YES  NO If no, explain how the care schedule varies:

________________________________________________________________________________________________________________________

Care 4 Kids PPA (rev. 7/2019) Page 4 of 5

Parent Name: C4K Case Number:

SECTION 3, CONTINUED: CHILDREN IN CARE (To be c omp lete d togeth er b y Pa rent and Pro vider)

CHILD #3

/ /

LAST NAME FIRST NAME M.I. DATE OF BIRTH

Date care started: How much is the parent charged per week? $

Are you charging a mandatory registration fee for this child at this time?  YES  NO If yes, how much is the registration fee? $______________

Are you related to this child?  YES  NO If related, specify your relationship to the child:

 Grandparent/Great Grandparent  Aunt/Uncle  Sibling  Other: ___________________

CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (circle AM or PM)

Day of the Week

Schedule 1 Begin Time Schedule 1 End Time Schedule 2 Begin Time Schedule 2 End Time

Sunday

_____:_____ AM PM _____:_____ AM PM _____:_____ AM PM _____:_____ AM PM

Monday

_____:_____ AM PM

Tuesday

_____:_____ AM PM

Wednesday

_____:_____ AM PM

Thursday

_____:_____ AM PM

Friday

_____:_____ AM PM

Saturday

_____:_____ AM PM _____:_____ AM PM _____:_____ AM PM _____:_____ AM PM

Is this child care schedule the same each week?  YES  NO If no, explain how the care schedule varies:

SECTION 4: PROVIDER CERTIFICATION ( To be co mp leted by Prov ide r)

I certify that:

1) I am the individual or program that is providing care to the children listed on this form. I am at least 20 years of age and capable

of providing safe and competent child care services. I do not have a disability, impairment or health problem that would

prevent me from caring for the children.

2) Care will be given at the location specified on the form. I am responsible for reporting changes in the hours of care, the amount

I charge for services, if the child stops attending care, and changes in the location where care is given. I must also inform Care 4

Kids of any changes in my criminal or child abuse/neglect history. Changes must be reported within 10 days.

3) For each child in my care, I have the name of the child’s primary care physician and health insurance provider and proof that

each child is up to date with his or her immunizations and health screening exams.

4) I understand and agree that the Office of Early Childhood and Care 4 Kids may verify information listed on this form

independently without prior authorization, including criminal and child abuse/neglect background checks.

5) I understand that this agreement is between the parent and the provider. It is not a contract with Care 4 Kids or the State of

Connecticut. Neither Care 4 Kids nor the State of Connecticut employ me. I am an independent contractor and will receive a

1099 tax form for monies received from Care 4 Kids.

6) Care 4 Kids may not cover my total charges. The parent is responsible for any costs that are not paid by Care 4 Kids.

7) I may be required to repay benefits that were paid to me in error. I may also be subject to criminal or civil charges if I knowingly

omit, misrepresent or provide false information to Care 4 Kids or if I do not report changes in a timely manner that affect

payments or my eligibility for this program. I may be liable for all penalties associated with crimes, including, but not limited to,

larceny by defrauding a public community, conspiracy to commit larceny by defrauding a public community, vendor fraud,

forgery, false statement and other relevant crimes pursuant to Title 53a of the Connecticut General Statutes.

8) I must submit a completed invoice to receive payment. Invoices are issued to me when payment is approved and monthly

thereafter. I will have 120 days to submit the completed invoice in order to be paid.

9) To be eligible for payments, (1) I will abide by State of Connecticut health and safety regulations as applied to me (either as a

licensed or unlicensed provider), and (2) I will cooperate with the State of Connecticut and its designees in program audits and

fraud prevention activities, including any site visits that may be conducted to my home, child care site or place of employment.

10) I understand I must complete the orientation and annual training requirements in order to be eligible for payment. For more

information on specific provider requirements, visit www.ctcare4kids.com.

11) I have read and understand the information contained in this form and certify that all of the information I have provided is true

and correct to the best of my knowledge.

12) I understand that if I am licensed, I must report any child fatalities and any injuries that result in a child being admitted to a

hospital that occur while a child is in my care to The Office of Early Childhood, Licensing Division at 1-800-282-6063.

Provider Name (please print):

LAST NAME FIRST NAME M.I.

Provider Signature: / /

DATE

Care 4 Kids PPA (rev. 7/2019) Page 5 of 5

Parent Name: C4K Case Number:

SECTION 5: PARENT CERTIFICATION (To be com plet ed b y Pa rent)

I certify that:

1) I have selected the provider identified above to care for my children while I work or attend an approved activity.

2) I will report any changes in child care arrangements, household income that exceeds 85% of the State Median Income

guidelines, loss of a job or ending of an approved activity, if the child receiving Care 4 Kids benefits is no longer in the home,

or my residential address to Care 4 Kids within 10 days of a change.

3) I am responsible to pay the provider any costs not covered by Care 4 Kids.

4) I understand and agree that Care 4 Kids may contact the provider listed above and the provider may contact Care 4 Kids

concerning my eligibility and payment amounts.

5) I may be required to repay benefits that were paid in error on my behalf. I may also be subject to criminal or civil charges if I

knowingly omit, misrepresent or provide false information to Care 4 Kids or if I do not report changes in a timely manner that

affect payments or my eligibility for this program. I may be liable for all penalties associated with crimes, including, but not

limited to, larceny by defrauding a public community, conspiracy to commit larceny by defrauding a public community,

vendor fraud, forgery, false statement and other relevant crimes pursuant to Title 53a of the Connecticut General Statutes.

Parent Name (please print):

LAST NAME FIRST NAME M.I.

Parent Signature: / /

DATE