CC Eligibility Documentation Log and Desk Reference



Child Care ServicesEligibility Documentation Logand FormsOverviewThe Texas Workforce Commission (TWC) has developed sample forms to assist Local Workforce Development Boards (Boards) in collecting the information necessary to verify eligibility criteria Child Care Services. Boards may use the sample forms as presented, modify the sample forms to better fit specific local workforce development area needs, or design their own forms.In addition to the Documentation Log, the following sample forms are available:Employment/Income Verification formResidency Information form (for Homelessness determinations)General InstructionsA documentation log is only necessary for At-Risk, Transitional, TANF Applicant, and Homeless eligibility determinations. Eligibility determinations for Choices, SNAP E&T, and DFPS child care (including Former DFPS) are made by the respective programs and agencies that refer customers for child care services. Boards must be aware that The Workforce Information System of Texas (TWIST) is the primary repository for Child Care eligibility determination data. Documentation logs are used in support of data entry into TWIST. The log provides a comprehensive list of Child Care Services eligibility criteria aligned with the acceptable associated source documentation.Boards may adopt TWC policy and use the sample documentation log and forms or they may modify the sample log and forms as needed to reflect local policy.At a minimum, documentation logs must contain the following:Identifying InformationNameTWIST identification (ID) or Social Security number (SSN)DateEligibility CriteriaAge and citizenship status of childReason for careIncome information (except for Homeless eligibility)Criteria for homelessnessSupporting DocumentationA list of acceptable documentation for each criterionCompleted documentation logs and copies of all collected source documentation must be maintained. Failure to completely and accurately document a customer’s eligibility could result in a finding of Improper Payment.Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LastFirstMITWIST ID: FORMTEXT ?????Date of Application/Renewal: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Basic Eligibility for Child Care ServicesTo receive services, all children must meet the following eligibility criteria. Supporting documentation for each criterion must be maintained at the Board level. One source document from each list is sufficient to meet documentation requirements for the particular eligibility criteria. Complete this section for each child who requires care.Name of Child Requiring Care: FORMTEXT ?????______________________________ FORMTEXT ?????______________________________________First LastApplicant’s relationship to child: FORMCHECKBOX Parent/guardian FORMCHECKBOX Person standing in loco parentisCHILD ELIGIBILITY CRITERIAACCEPTABLE DOCUMENTATION FORMCHECKBOX Child’s Age (under 13; under 19 if disabled) FORMCHECKBOX Birth certificate FORMCHECKBOX Current U.S. passport FORMCHECKBOX Hospital record of birth FORMCHECKBOX Church or baptismal record FORMCHECKBOX Public assistance/social service records FORMCHECKBOX School records/school id card FORMCHECKBOX Immigration and Naturalization Service records FORMCHECKBOX Native American tribal document FORMCHECKBOX Adoption papers or records FORMCHECKBOX Child support paternity records FORMCHECKBOX Divorce or court custody decrees FORMCHECKBOX Child’s Citizenship/Immigration StatusNote: Only the child’s status must be verified; a parent’s citizenship or immigration status is not criteria for eligibility.Citizenship: FORMCHECKBOX Birth certificate FORMCHECKBOX Current U.S. passport FORMCHECKBOX Hospital record of birth FORMCHECKBOX Church or baptismal record FORMCHECKBOX Public assistance/social service recordsLegal Immigrant/Qualified Alien: FORMCHECKBOX Immigration form I-551 (“green card”) FORMCHECKBOX Immigration form I-94/I-94a, stamped with applicable rule citation(s) FORMCHECKBOX Immigration form I-571 (Refugee Travel Document) FORMCHECKBOX Order from immigration judge FORMCHECKBOX Cuban/Haitian passport showing 501(e) FORMCHECKBOX USCIS petition and supporting documents FORMCHECKBOX Child with disabilities OR FORMCHECKBOX Not applicable FORMCHECKBOX Supplemental Security Income (SSI) benefits statement FORMCHECKBOX Early Childhood Intervention (ECI) program contact FORMCHECKBOX Head Start contact that identifies the child as having a disability FORMCHECKBOX Public school special education services, including PPCD, contact FORMCHECKBOX Statement or letter from a qualified clinicianAttach an additional page for each child who requires care.Eligibility for At-Risk, Transitional, TANF Applicant & Homeless Child Care ServicesTo receive At-Risk or Homeless Child Care Services, families must meet the following eligibility criteria. Supporting documentation for each criterion must be maintained at the Board level. One source document from each list is sufficient to meet documentation requirements for the particular eligibility criteria.FAMILY ELIGIBILITY CRITERIAACCEPTABLE DOCUMENTATION FORMCHECKBOX Family IncomeNote: Documentation should be provided for each applicable income source, for each family member. FORMCHECKBOX Pay stubs FORMCHECKBOX Employment/Income Verification form or letter FORMCHECKBOX Homelessness determination – Residency Information form FORMCHECKBOX Workers Compensation documentation/statement FORMCHECKBOX SSDI statement FORMCHECKBOX Retirement/Pension statement FORMCHECKBOX Quarterly estimated tax for self-employed persons (Schedule C) FORMCHECKBOX Self-employment verification form FORMCHECKBOX Family or business financial records FORMCHECKBOX Award letter from Veterans Affairs FORMCHECKBOX Bank statement FORMCHECKBOX Compensation award letter or offer letter FORMCHECKBOX IRS form 1099-DIV, -INT, for dividends or interest FORMCHECKBOX IRS form 1040 Schedule D for capital gains FORMCHECKBOX Resident of LWDA FORMCHECKBOX Copy of current utility bill FORMCHECKBOX Public assistance/social service records FORMCHECKBOX School records FORMCHECKBOX Pay stub (if address is printed on stub) FORMCHECKBOX Rent receipt (showing current address) FORMCHECKBOX Lease agreement FORMCHECKBOX Mortgage statement FORMCHECKBOX Section 8 award letter FORMCHECKBOX Homelessness determination – Residency Information form FORMCHECKBOX Reason for CareEmployment FORMCHECKBOX Pay stubs with hours worked FORMCHECKBOX Employment/Income Verification form or letter FORMCHECKBOX Self-employment verification form FORMCHECKBOX Financial records for self-employed persons FORMCHECKBOX Quarterly estimated tax for self-employment (Schedule C)Education FORMCHECKBOX Transcript from education/training programOR Training FORMCHECKBOX Statement from education/training provider FORMCHECKBOX Tuition statement with semester hours FORMCHECKBOX Admissions letter FORMCHECKBOX Other official document from an education/training provider indicating current enrollmentCase Manager/Intake Notes: FORMTEXT ?????Texas Workforce Solutions Staff SignaturePrint NameDateManager/Reviewer SignaturePrint NameDateEligibility Documentation FormsThe Texas Workforce Commission has developed standardized forms to assist Local Workforce Development Boards (Boards) in collecting the information necessary to verify the multiple Child Care Services eligibility criteria. Boards may modify these forms to meet specific needs; however, all required data elements must remain the same.The following form instructions are included:Instructions for Completing Employment/Income Verification FormInstructions for Completing Residency Information FormInstructions for Completing the Employment/Income Verification FormThe purpose of this form is to document a family’s income and work hours at time of application when pay stubs are not available. The most likely situations that will require the Employment/Income Verification Form are when a family member:has just begun new employment and check stubs are not yet available;has pay documents that reflect gross pay, but not hours worked; oris an employee but is paid in cash by their employer.NOTE: To ensure eligibility determination processes that are both family-friendly and employer-friendly, Boards should use this form only when employment income and hours cannot be otherwise verified. Specific InstructionsIf a family member reports employment income, but lacks pay stubs, Workforce Solution staff should provide the parent with the Employment/Income Verification form to be completed by the family member and his or her employer.Step 1: Determine if the customer has pay stubs for each job for the previous three month period. Does the family member have pay stubs for the previous three months?If the family member has less than three months of pay stubs, is YTD information available that includes the last three months?Is the employment new (less than three months old)? Do the pay stubs reflect hours worked? Step 2: If the employment is new, pay stubs are not available, or the pay stubs do not reflect hours worked, WFS staff should assist the family member with completing their portion of the Employment/Income Verification form and provide instructions for asking the employer to complete their portion. Step 3: WFS staff should ensure customers and employers are aware of the multiple ways the form may be completed and returned, including:MailEmailFaxTelephone verificationInstructions for Completing the Residency Information FormThe purpose of this form is to verify a family’s residency status at time of application and to document if a family meets the definition for homelessness as defined in the McKinney-Vento Homeless Assistance Act. This form is only necessary when a family does not have, or is suspected of not having, a permanent, fixed, and adequate residence.Homelessness is defined in the McKinney-Vento Act as children who are lacking a nighttime residence that is fixed, regular, and adequate. This includes children who:are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings;are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and are migratory children who qualify as homeless because they are living in circumstances described above.Fixed means stationary, permanent, and not subject to change.Regular means consistent; used on a regular (e.g., nightly) basis.Adequate means sufficient for meeting both the physical and psychological needs typically met in home environmentsSpecific InstructionsStep 1: The first page of the Residency Information form should be completed by the parent(s), with the assistance of Workforce Solutions staff as needed. Step 2: If the information the parent provides indicates that the family may be homeless, the Workforce Solutions staff should ask additional questions as needed to get a better sense of the family’s circumstances.Step 3: Determining whether a particular child or family fits the definition of homeless is done on a case-by-case basis. To make a determination of homelessness: see if the family’s situation fits into one of the specific examples of homelessness (listed in above in 1-7); and if not,consider if the family is in another situation that would fit the definition of homelessness by not meeting the fixed, regular, and adequate standard. Step 4: The Workforce Solutions staff should use the information provided by the parent to complete the second page of the form. If Workforce Solutions staff makes a positive determination that the family is homeless, caseworker/intake notes should document the reason(s).Helpful Hints When Talking to Families Who May be Experiencing HomelessnessAvoid using the word “homeless,” as the stigma associated with the word may lead parents to insist they are not homeless even though their living situation would fit the McKinney-Vento definition. Explain that the purpose for asking questions about their living arrangement is to determine if they are eligible for some additional supports and request that the parent/guardian provide you with the information needed to make a determination. Understand that families may be hesitant to answer questions for various reasons that include a desire for privacy, concerns related to domestic violence, or fear of losing their housing or custody of their children; however, in most cases you will be able to gather enough information to make a determination.Respect the family’s privacy by talking to them in a private space where other customers cannot overhear the conversation.Conduct a conversation with the family using applicable questions provided in the following sections.Questions to Ask Parents for Information GatheringFixed:Is this a permanent arrangement or just temporary?Are you looking for another place to live?Do you plan to move out soon?Why are you staying in your current place?Where were you living right before this place? Why did you leave?Where would you go if you couldn’t stay where you are?Are you staying with friends/relatives just for a little while? Did you and your friends/relatives decide to move in together and share a home and expenses for the long term? Or is this a temporary situation for you? Could your friends/relatives ask you to leave if they wanted to?Are you all sharing the home equally, or are you more like guests in the home?Regular:Do you stay in the same place every night?Do you have a key to the place where you are living?Do you move around a lot?How long have you been at that place? How long do you plan to stay? How long did you live in your last place? Adequate:How many people are living in the home? How many bedrooms/bathrooms does it have? Are you and your children sharing a room? How many people are staying in one room? Are you and your children sleeping in a bedroom, or in a public area, like a dining room?Does the home have heat/electricity/running water?What condition is the home in? Does it keep out rain and wind? Is it safe? Is it warm and dry?Child Care ServicesEmployment/Income VerificationEmployee Name: FORMTEXT ?????TWIST id: FORMTEXT ?????NOTE TO EMPLOYER: This is your authorization to release the information concerning my employment as required below. In order to establish eligibility for child care services, verification of income actually received for the period FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ????? to FORMTEXT ????? / FORMTEXT ?????/ FORMTEXT ????? is needed. Please complete this form as soon as possible as it is required before I, or a member of my family, can be determined eligible for the program.Your cooperation and prompt return of this information is appreciated. Thank you,Date: FORMTEXT ?????Signature of EmployeeTO BE COMPLETED BY THE EMPLOYEREmployer’s Name: FORMTEXT ?????_______________________________________________________________________________ Street Address: FORMTEXT ????? ___City: FORMTEXT ?????_________________ State: FORMTEXT ?????_ Zip: FORMTEXT ?????______Telephone: FORMTEXT ?????___________ ___ __Employed From: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ????? to FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ????? Position: FORMTEXT ?????_________________________ Month/Day/Year Month/Day/YearGross Pay (before deductions) per pay period: $ FORMTEXT ?????____ Average # of Hours Scheduled per Week: FORMTEXT ?????___Pay Frequency: FORMCHECKBOX Weekly FORMCHECKBOX Every Two Weeks FORMCHECKBOX Twice a Month FORMCHECKBOX MonthlyTypical Work Schedule (i.e., Monday – Friday 8-5:00):_________________________________________________________________ ___________________________________Overtime Pay Frequency: FORMCHECKBOX Frequently FORMCHECKBOX Rarely FORMCHECKBOX Never Estimated Monthly Overtime Pay: __________ Does this Employee Receive Tips: FORMCHECKBOX Yes FORMCHECKBOX No Estimated Monthly Tip Income: ____________ Does this Employee Receive Bonuses: FORMCHECKBOX Yes FORMCHECKBOX No Estimated Monthly Tip Income: ____________ Comments:_____________________________________________________________________________________________________Name and Title of Employer Representative (PLEASE PRINT)_________________________________________________________ ________________________________________Signature of Employer Representative Date TO BE COMPLETED BY WORKFORCE SOLUTIONS STAFFPLEASE RETURN TO:Workforce Solutions Office Name: FORMTEXT ????? Attn: (Staff name): FORMTEXT ?????BY MAIL: Street Address: FORMTEXT ????? City: FORMTEXT ?????State: _ FORMTEXT ?????Zip: FORMTEXT ?????BY FAX: FORMTEXT ?????__________________________________________________BY EMAIL: FORMTEXT ?????__________________________________________________This form may be completed by Workforce Solutions Office staff if verified by telephone contact indicating who supplied the information and the date the telephone contact was made.Texas Workforce Solutions Staff SignaturePrint NameDateManager/Reviewer SignaturePrint NameDate Staff Comments: FORMTEXT ?????Residency Information Form Name: FORMTEXT ?????__________________________________ TWIST id: FORMTEXT ?????__________TO BE COMPLETED BY PARENTIs your current residence Temporary or Permanent? (Circle one)Which of the following situations describes your family’s current nighttime residence (you can choose more than one): FORMCHECKBOX House or apartment with parent or guardian FORMCHECKBOX Motel, car, or campsite FORMCHECKBOX Shelter or other temporary housing FORMCHECKBOX With friends or family members (other than or in addition to parent/guardian)If your family is living in shared housing, please check all of the following reasons that apply: FORMCHECKBOX Loss of housing FORMCHECKBOX Economic situation FORMCHECKBOX Temporarily waiting for house or apartment FORMCHECKBOX Provide care for a family member FORMCHECKBOX Living with boyfriend/girlfriend FORMCHECKBOX Loss of employment FORMCHECKBOX Parent/Guardian is deployed FORMCHECKBOX Other (Please explain): _ FORMTEXT ?????_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE, AND UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE TERMINATION OF CHILD CARE SERVICES AND/OR PENALTIES AS SPECIFIED BY LAW.PARENT’S SIGNATURE DATETO BE COMPLETED BY WFS STAFFDoes the family’s nighttime residence meet the following standards? (See form instructions for guidance) FORMCHECKBOX Fixed FORMCHECKBOX Regular FORMCHECKBOX AdequateOutside agency verification of residency information (if available): FORMCHECKBOX Local school district FORMCHECKBOX Head Start program FORMCHECKBOX Homeless shelter FORMCHECKBOX Transitional housing program FORMCHECKBOX Other social services or workforce programDescribe any verifications obtained, including contact information and dates: FORMTEXT ?????Case Manager/Intake Notes: FORMTEXT ?????____________________________________ ______________________________________________WFS STAFF SIGNATURE PRINT NAME DATE____________________________________ ______________________________________________WFS MANAGER/REVIEWER SIGNATURE PRINT NAME DATE ................
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