AUTHORIZATION PLACEMENT AGREEMENT (APA)

CORRESPONDENCE ID: 50
Test : Creative Information Technology Inc
7799 Leesburg Pike, Suite 500 North, Falls Church, VA 22043
Falls Church, VA 22043
APA Generated Date: 10/5/2021
JAMES GARRETT PARENT/CARETAKER: ADDRESS:
7799 LEESBURG PIKE LITTLE, JAKE 6287 EIGHTH AVE
FALLS CHURCH, VA 22043 SAN ANTONIO, VA 78521
(979) 837-6446 Ph. No: (525) 361-9972
CASE IDENTIFICATION:
Locality: SAN ANTONIO Case#: C00006 CCAR Team: TEAM 1
P00001 Child Care Worker: Income Fee Scale Update for 12/1/2021

MONTHLY CO-PAY AMOUNT: $ 0.00 MONTHLY CO-PAY EFFECTIVE DATE:

DATE OF APA BEGIN APA END SPECIAL REGISTRATIO ABSENCES AUTHORIZATION

CHILD NAME CHILD ID
BIRTH DATE DATE NEEDS RATE N FEE USED YTD STATUS
HARRY WOOD 000045 1/6/2018 7/1/2021 6/30/202 No $ 0.00 0 AUTHORIZED
2

AGE RANGE FULL DAY RATE PART DAY RATE SPECIAL NEEDS FULL SPECIAL NEEDS PART
DAY RATE DAY RATE
Infant (0 up to 15months) $ 37.00 $ 26.00 $ 74.00 $ 52.00
Toddler (16 months up to 23 months) $ 35.00 $ 25.00 $ 70.00 $ 50.00
Preschool (24 months up to school age) $ 33.00 $ 24.00 $ 66.00 $ 48.00
School age (5 years by 9/30 up to 13 years) $ 30.00 $ 21.00 $ 60.00 $ 42.00
NOTE: If the Special Needs Rate indicator is “Yes” for any child. Please refer to the Special Needs Rate columns for the authorized rate for that child.

Comments: Parent fees have been updated for new income fee scale effective on 12/1/2021
 AUTHORIZATION PLACEMENT AGREEMENT (APA)
CORRESPONDENCE ID: 50

JAMES GARRETT LITTLE, JAKE

7799 LEESBURG PIKE 6287 EIGHTH AVE
FALLS CHURCH, VA 22043 SAN ANTONIO, VA 78521
CCAR Team # : TEAM 1

Varied Schedule School Aged

Schedule: Full Day (FD) 5-12 hrs.
Child Details Maximum # of days SD- School Day
Part Day (PD) less than 4 hrs. and 59 min.
per week FD- Full Day
Family Co-
Effective
First Name Last Name pay (per S M T W T F S FD PD SD FD
Date
child)

HARRY WOOD 4/1/2015 $ 0.00 FD FD PD PD FD

COUNTY CCAR AUTHORIZED REPRESENTATIVE OF VENDOR

Signature of Case Supervisor
Please sign and return to CCAR immediately to confirm this Authorized
Placement Agreement
I HEREBY AGREE TO PROVIDE THE SERVICE REQUESTED ABOVE IN ACCORDANCE
WITH OUR AUTHORIZED PLACEMENT AGREEMENT. I UNDERSTAND THAT
FAMILY CO-PAY LISTED IS A MONTHLY CO-PAY FOR THIS AGREEMENT ONLY.
Date Phone

Signature of Authorized
Signature of Case Worker Date Phone Date Phone
Representative of Vendor
Parent/Caretaker Acknowledgement :
I agree to pay the monthly family co-pay and additional fees charged by the vendor including overtime fees. As a courtesy, give the vendor two weeks
notices before the child’s last day in care.

Signature of Parent/Caretaker Date