Subsidized Eligibility Child Care Policy Manual

Eligibility Determinations for
Subsidized Child Care Policy Manual

REVISED
September 2016
Table of Contents
Introduction ……………………………………………………………………… 4
Section 100 – General Provisions

100.1 – Role of the Office of the State Superintendent of Education……………. 6
100.2 – Role of the Eligibility Staff……………………………………….……… 6
100.3 – Confidentiality of Information …………………………………………... 6
100.4 – Non-Discrimination Policy ……………………………………………… 6
100.5 – OSSE DEL Management Information System ………………………….. 7
100.6 – Case Record Requirements ……………………………………………… 7
Section 200 – Eligibility for Subsidized Child Care

200.1 – Eligibility Requirements ………………………………………………… 9
200.2 – Eligibility Requirement: Age …………………………………………… 9
200.3 – Eligibility Requirement: Legal Relationship …………………………… 9
200.4 – Eligibility Requirement: Citizenship or Legal Status…………………… 10
200.5 – Eligibility Requirement: Residency ………..……………………........... 10
200.6 – Eligibility Requirement: Need for Subsidized Care…………………….. 11
200.7 – Eligibility Requirement: Income Threshold……………………………... 17
Section 300 – Eligibility Determination and Placement Process

300.1 – Pre-Screening …………………………………………………………… 22
300.2 – Intake Interview ………………………………………………………… 22
300.3 – Supporting Documentation ……………………………………………… 24
300.4 – Denial of Application …………………………………………………… 32
300.5 – Placement ……………………………………………………………….. 33
300.6 – Admission Form ………………………………………………………… 34
Section 400 – Family Co-Payment

400.1 – Co-Payment Requirements Based on Need …………………………….. 35
400.2 – Determination of Family Size …………………………………………… 36
400.3 – Adjusted Annual Gross Family Income Determination…………………. 36
400.4 – Application of the Co-Payment Scale ………………………………....... 37
400.5 – Co-Payment for Multiple Children …………………………………....... 38
400.6 – Change in Co-Payment ………………………………………………….. 38
400.7 – Payments to Providers……………………………………………………. 38
Section 500 – Redetermination of Eligibility

500.1 – Eligibility Period ………………………………………………………… 40
500.2 – Eligibility Redetermination: Documentation ……………………………. 43
500.3 – Eligibility Redetermination: TANF Parent ……………………………… 43
500.4 – Eligibility Redetermination: Graduated Phase Out ……………………... 43
500.5 – Eligibility Redetermination: Applicant’s Failure to Respond ………...... 44
ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 2

Section 600 – Termination of Subsidized Child Care
600.1 – Reason for Termination…………………………………………………. 46
600.2 – Fraud ……………………………………………………………………. 46
Section 700 – Appeal and Administrative Hearings

700.1 – Availability of an Appeal/ Administrative Hearing.……………………. 49
Section 800 – Payments to Providers

800.1 – Payment ………………………………………………………………… 53
800.2 – Payroll Processing ……………………………………………………… 53
800.3 – Payment Errors …………………………………………………………. 54
800.4 – Overpayments ………………………………………………………….. 55
800.5 – Underpayments …………………………………………………………. 55
800.6 – Responsibilities for Attendance Reporting and Payment ………………. 55
800.7 – Holidays ………………………………………………………………… 56
800.8 – Staff Development ……………………………………………………… 57
800.9 – Snow and Inclement Weather Days …………………………………….. 57
800.10 – Attendance …………………………………………………………...... 57
Section 900 - Glossary of Key Terms …………………………………………. 58
Appendices
Appendix 1: Subsidized Child Care Case Record Requirements
Appendix 2: Record of Case Action Form
Appendix 3: Application for Subsidized Child Care Services
Appendix 4: Child Care Admission Form (Traditional and Non-Traditional)
Appendix 5: Child Care Referral Form
Appendix 6: Maximum Income Guidelines for Subsidized Child Care
Appendix 7: Calculation of Parent’s Income Form
Appendix 8: 2009 Sliding Fee Scale
Appendix 9: Parent Fee Change Form
Appendix 10: Eligibility Review Appointment Letter
Appendix 11: Notice of Termination of Child Care Services
Appendix 12: Payment Summary Error Report
Appendix 13: Eligibility Checklists

Introduction
The District of Columbia’s (DC) child care subsidy program, administered by DC’s Office of the
State Superintendent of Education (OSSE), provides financial assistance to families with eligible
children seeking access to child care while the parent(s) or guardian(s) work or attend job
training or educational programs. While the original purpose of DC’s subsidized child care
program was solely to assist eligible families with child care costs, DC has recently shifted the
purpose of the subsidized child care program to ensuring stability of care arrangements for
children, in alignment with national trends, by making key changes that promote continuity of
care and family-friendly policies.
On November 19, 2014, President Obama signed the federal Child Care and Development Block
Grant Act of 2014, effective November 19, 2014 (P.L. 113-16, 42. U.S.C. § 9858 et seq.)
(CCDBG Act), reauthorizing the CCDBG Act for the first time since 1996. The new law made
significant changes to the Child Care and Development Fund (CCDF) program, designed to
promote children’s healthy development and safety, improve the quality of child care, and
provide support for parents who are working or are in training or education. The CCDBG Act
established the following priorities: increasing access to child care; reducing burden for families
to obtain child care; and increasing access for special populations (including children
experiencing homelessness, children with special needs, and families with very low income).
Additionally, on September 30, 2016, the U.S. Health and Human Services Administration for
Children and Families issued a Notification of Final Rulemaking to amend CCDF regulations, 45
C.F.R. Part 98, based on the changes to the CCDBG Act.
Upon passage of the significant federal legislation, OSSE conducted a comprehensive review of
the 2009 Policy Manual and determined the need to revise the guide to comply with the CCDBG
Act, its implementing regulations and DC’s 2016-18 CCDF State Plan. All revisions and
additions provided herein are effective September 30, 2016.
This manual, the “2016 Eligibility Determinations for Subsidized Child Care Policy Manual”
(Policy Manual), is intended to help ensure consistent and accurate application and
implementation of eligibility determination for children and their families by DC government
agencies, including the Office of the State Superintendent of Education (OSSE)1 and Department
of Human Services Child Care Services Division (DHS CCSD), and authorized Level II child
development facilities.
1
Effective April 1, 2008, pursuant to the Public Education Reform Amendment Act of 2007 (D.C. Law 17-9, D.C.
Code Section 38-2601, et. seq.) most of the functions of the DC Office of Early Childhood Education (ECE) were
placed under OSSE. However, the Intake and Continuing Services Unit, Child Care Services Division, which
completes eligibility determinations for the child care subsidy program, remained with the Department of Human
Services (DHS). The Child Care Eligibility Monitors who were previously a part of the DHS CCSD under DHS
remained with ECE under OSSE, along with other staff performing monitoring and quality control functions.
Eligibility Monitors, along with other OSSE/DEL staff, will continue to interface with the DHS CCSD to ensure
children and families continue to receive services.

An understanding of DC’s child care delivery system is critical to ensure appropriate application
of the variables in determining eligibility and certifying children for placement in child
development facilities. Accordingly, this guide sets forth the procedures and framework for the:
 Roles and responsibilities of the DHS CCSD caseworker and the Level II Child
Development Facility eligibility staff in determining initial and continuing eligibility;
 Identification of factors that constitute eligibility for subsidized child care;
 Identification of appropriate documentation for eligibility decisions;
 Placement of children in an appropriate child development facility;
 Determination of proper subsidized co-payment calculations;
 Redetermination of eligibility or termination of eligibility; and
 Payments made to child development facilities caring for eligible children.
Eligibility decisions are based on adherence to the following federal and local laws including,
but not limited to:
 The CCDBG Act and the implementing regulations, 45 C.F.R. Part 98;
 The Day Care Policy Act of 1979, effective September 19, 1979 (D.C. Law 3-16, D.C.
Official Code § 4-401 et seq.) (Day Care Act);
 District of Columbia’s CCDF State Plan, current version;
 Chapter 2 of Title 5-A of the District of Columbia Municipal Regulations (5-A DCMR §
200 et seq.); and
 Any other relevant OSSE policy issuances.

SECTION 100
GENERAL PROVISIONS
100.1 ROLE OF THE OFFICE OF THE STATE SUPERINTENDENT OF EDUCATION
OSSE is designated as the lead agency in DC with primary responsibilities for the
planning and administration of child care subsidies funded by CCDF.
100.2 ROLE OF ELIGIBILITY STAFF
Eligibility staff are the DHS CCSD staff or the Level II child development facility staff
persons responsible for determining a family and child’s eligibility for subsidized child
care. The primary functions and responsibilities of the eligibility staff are to:
(1) Determine initial eligibility and redetermine eligibility of families and children for
subsidized child care services;
(2) Assist with appropriate placement for eligible children; and
(3) Determine the appropriate subsidy payment and parent(s) or guardian(s) co-
payment.
All eligibility staff shall have basic knowledge about DC’s subsidized child care program
as presented in the Policy Manual, including, but not limited to: the application process,
the eligibility factors, various program options and potential hours of operation, and fee
determination process and schedule; and articulate these details to all prospective
applicants.
In addition, all eligibility staff shall have knowledge of the requirements for each
eligibility category in which a referral is needed from another office and articulate the
steps for obtaining the referral to the applicant.
100.3 CONFIDENTIALITY OF INFORMATION
Any information related to a family or individual’s participation in the child care subsidy
program shall not be disclosed, shared or made available to any person, organization, or
provider without the prior written consent of the participant(s) or applicant(s). Any such
information will only be shared or disclosed in accordance with all confidentiality and
privacy protections as afforded by all applicable federal and local laws.
100.4 NON-DISCRIMINATION POLICY
All services shall be provided to applicants without regard to (actual or perceived) race,
color, religion, national origin, sex (including pregnancy), age, marital status, personal
appearance, sexual orientation, gender identity or expression, familial status, family
responsibilities, matriculation, political affiliation, disability, source of income, victim of

an intra-family offense, or place of residence or business (applies to housing and public
accommodations).
100.5 OSSE DEL MANAGEMENT INFORMATION SYSTEM
OSSE DEL uses a management information system (MIS) to store data for all children in
the child care subsidy program. Eligibility staff assigned to the case, whether in the DHS
CCSD office or in a Level II child development center, shall use the MIS to set up a new
applicant’s case and is expected to maintain and update case information as needed for
each child and family whose eligibility they determine throughout the period the family is
eligible.
All Level II child development centers must be trained for use of the MIS prior to taking
subsidized child care applications. The child care subsidy system computer modules
relevant to eligibility determination are the Client Entry (Child Care Intake) module and
the Child Care Assignment module. The following are some of the most important
features of each module:
 The Client Entry module must be updated at every eligibility review or when any
other changes are needed with a hard copy of the main intake and
employment/training screens filed in the paper case folder.
 The Assignment module must be completed to allow for payment for a child and must
be updated immediately when there is a change in assignment or termination. A hard
copy of the assignment screen should be filed in the paper case folder.
In addition, eligibility staff shall monitor applicants to identify families with children in
multiple sites. All cases with children in multiple sites shall be forwarded to the DHS
CCSD office to centralize the records for the entire family and alleviate the need for
families to travel to multiple sites for child care services. This will be the responsibility of
the assigned eligibility staff member at DHS CCSD if the record is active at DHS CCSD.
The DHS CCSD eligibility staff member must use a transmittal memorandum to
document receipt of the case record from the Level II eligibility staff member with a copy
given to the provider for their records.
100.6 CASE RECORD REQUIREMENTS
For each child receiving subsidized child care, eligibility staff shall establish and
maintain both:
(a) MIS Case Record: The eligibility staff shall set up the case record by entering all
information from the application into OSSE DEL MIS at the time of the
interview. If the applicant received services previously and is already in the
database, the eligibility staff shall confirm that the database is up-to-date with
current information; and

(b) Paper Case Record: The paper case record shall meet the requirements set forth
in Appendix 1: Subsidized Child Care Case Record Requirements. The paper case
record shall be properly secured, available at all times, and is subject to review by
OSSE eligibility monitors, DHS or OSSE DEL staff, or outside auditors.

SECTION 200
ELIGIBILITY FOR SUBSIDIZED CARE
OSSE maintains the final authority on eligibility for the child care subsidy program. The person
making the determination of eligibility for subsidized child care may be an employee of a DC
agency or a trained eligibility staff person at a Level II child development facility to which the
responsibility has been delegated by OSSE. In either case, that person is responsible for applying
the eligibility policies as set forth in this Policy Manual and in:
 The CCDBG Act and its implementing regulations (45 C.F.R. Part 98);
 DC’s CCDF State Plan;
 The Day Care Act;
 5-A DCMR § 200 et seq.; and
 Any other applicable OSSE policies.
Eligibility decisions by the DHS CCSD and Level II eligibility staff shall be subject to review by
OSSE.
200.1 ELIGIBILITY REQUIREMENTS
In order to be eligible for subsidized child care in DC, a child shall, at the time of eligibility
determination or redetermination:
(a) Be under 13 years old, or under 19 years old if the child has special needs;
(b) Reside with a parent(s), guardian(s), or adult with legal relationship to child;
(c) Be a citizen or legal immigrant in the United States;
(d) Be a resident of the District of Columbia;
(e) Meet the requirements for one of the following categories of need:
(1) Resides with parent(s) who are working or attending a job training or
education program;
(2) Resides with parent(s) who is seeking employment or engaging in job search;
or
(3) Receives, or need to receive, protective services or is considered a vulnerable
child, as defined herein; and
(f) Reside with a parent(s) or guardian(s) whose gross annual income does not exceed 250
percent of the federal poverty level or 85 percent of the DC Median Income based on
family size.
200.2 ELIGIBILITY REQUIREMENT: IS THE CHILD THE APPROPRIATE AGE?
The eligibility staff shall verify that the child for whom care is sought is under thirteen
(13) years old, or under nineteen (19) years old if a child has special needs.
200.3 ELIGIBILITY REQUIREMENT: DOES THE APPLICANT HAVE A VALID

LEGAL RELATIONSHIP WITH THE CHILD FOR WHOM CARE IS SOUGHT?

The eligibility staff shall verify that the adult requesting child care has a valid legal
relationship to the child(ren) (such as parent, guardian, custodian, foster parent, or TANF
Payee).
The eligibility staff may accept the applicant’s statement in regard to marital status.
However, whenever this statement is contradicted either by documentation seen or by
behavior observed, the applicant must be required to clarify and confirm status by
providing additional proof of evidence.
200.4 ELIGIBILITY REQUIREMENT: IS THE CHILD A CITIZEN OR HAVE LEGAL

IMMIGRATION STATUS?
The eligibility staff shall verify that each child considered for subsidized child care is a
United States citizen or national of the United States, Puerto Rico, Guam, U.S. Virgin
Islands, American Samoa or the Northern Mariana Islands or otherwise in the country
legally.
Children for whom federal child care assistance is sought must meet citizenship criteria
prior to being found eligible for such assistance. Applicants who cannot provide
verification of the child’s citizenship or immigration status are not eligible for subsidized
child care. Only the citizenship and immigration status of the child is to be considered. A
child’s eligibility for subsidized child care shall not be based upon the citizenship or
immigration status of their parent or the provision of any information about the
citizenship or immigration status of their parent.
200.5 ELIGIBILITY REQUIREMENT: IS THE CHILD A RESIDENT OF THE

DISTRICT OF COLUMBIA?
The eligibility staff shall verify the child is a resident of the District of Columbia, as
defined herein and in accordance with the following:
(a) Child Experiencing Homelessness. If an eligibility staff member identifies or an

applicant indicates that the family, and therefore the child, is experiencing
homelessness, then the family is given a 60 day grace period to provide residency
documents. The eligibility staff at the Virginia Williams Resource Center
completes OSSE’s Child Care Referral Form (Appendix 5) as acceptable
documentation until the records can be provided.
(b) Additional Residency Confirmation – Tax Deduction. If an applicant submits a

pay statement, the eligibility staff shall check each applicant’s pay statement for
tax deduction information. Each applicant for subsidized child care shall pay DC
state taxes. The eligibility staff shall request additional documentation whenever
tax deductions from Maryland, Virginia or another state are identified. The
applicant must confirm DC taxes are being paid regardless of whether other
residency documentation has been provided, by doing one of the following:

(1) If making a new application, the applicant must have the corrected
deductions before the child is approved for placement (within the 30 day
timeline bring one pay statement showing DC tax);
(2) If a review of eligibility is being completed, the correction must be

documented as requested within 15 days after the review appointment.
The applicant must follow up by supplying a pay statement reflecting the
change no later than 30 days after the review appointment; or
(3) If the applicant works outside DC and tax payment to the other jurisdiction
is required by the employer, the applicant must supply written
documentation from their employer which states that it is company policy,
and that the company knows the person to be a DC resident. The parent
must also provide the most recent tax return or W-2 to show that he/she is
also paying DC taxes.
(c) Exceptions to the Residency Requirement. The following children may reside
outside of DC, however they shall be placed in a DC child development facility in
order for a subsidy provider to be paid, with the exception of a relative care
request, where the provider may reside in Maryland or Virginia:
(1) Foster Child. A foster child may reside with a foster parent(s) or
guardian(s) outside of the DC (in the metropolitan area) and still receive
child care services;
(2) Child under Protective Services. A child under protection of the DC

Child and Family Services Agency or the DC Superior Court, or living
with a relative or guardian in Maryland, Virginia or another state; or
(3) DC Ward. A child under the protection of DC, but placed in Maryland,
Virginia or another state by the DC agency. This ward may receive
subsidized child care in DC up until the age of nineteen (19) years. Note:
If the child(ren) of this applicant are not officially under protection, the
family is not considered a Protective Services case for child care
purposes. The applicant must qualify for child care based on another
category, such as training or employment, and must be assessed for a co-
payment if employed.
200.6 ELIGIBILITY REQUIREMENT: HAS THE APPLICANT DEMONSTRATED A

NEED FOR SUBSIDIZED CHILD CARE?
(a) An applicant shall demonstrate a need for subsidized child care. In order to meet this
eligibility requirement, a child shall fall into one of the following need categories:

(1) Reside with parent(s) (2) Reside with (3) Receive, or need to
or guardian(s) who are parent(s) or receive, protective
working or attending a job OR guardian(s) who is OR services, or be
training or education seeking employment considered a vulnerable
program. or engaging in job child, as defined herein.
search
This includes the following This includes the This includes the
classifications: following following classifications:
 Working classifications:  Children under
 Job Training or  TANF recipients; Protective Services;
Undergraduate Program  TANF Payee; or  Children with special
 Participants in Food  Verified Job needs;
Stamp Employment/ Search.  Children experiencing
Training Program; homelessness;
 TANF recipients;  Children in foster care;
 TANF Payee; or  Children of Adults
 Teen or Young Adult with Disabilities
Parent.  Children of recipients
of vocational
rehabilitation services.
Whenever both parents/guardians reside in the household with the children, both
parent(s) or guardians must qualify for the program. Each one (1) must be employed or
meet one of the need categories above. The income of both parents/guardians must be
combined. This is required regardless of whether or not they are legally married.
(b) The following tables describe the various classifications under each of the three
need categories.
(1) A child shall reside with parent(s) or guardian(s) who are working or
attending a job training or education program:
WORKING OR ATTENDING A JOB TRAINING OR EDUCATION PROGRAM

Working This group of applicants includes parent(s) and guardian(s) participating
Parent(s) or employed for a minimum of 20 hours per week. In a two parent(s) or
Guardian(s) guardian(s) household, both parent(s) or guardian(s) must work or participate
in valid qualifying activity for a minimum for 20 hours per week. The
timeframe that child care is requested and the parent(s) or guardian(s) work
schedule must match.
Job Training This group of applicants attends a training or undergraduate program for a
or minimum of 20 hours weekly. The applicant may also combine a training or
Undergraduate undergraduate program with employment to meet the 20 hour weekly
Program requirement.
Training The eligibility staff shall confirm the training program

meets the following requirements with an official at the
training program. All details of any conversations,
including the date and contact person, must be recorded in
the case record. Valid training activities shall include
preliminary training or job training.
Preliminary Training. A basic training provided before

job skills training, to enable the person to be employable.
These include English as a Second Language courses for
foreign-born adults and GED classes for adults. Children
eligible for subsidized child care pursuant to this subsection
may not be provided for longer than one year in this case.
Job Training. Acceptable job training program shall:
(1) Provide instruction in specific job skills (i.e. computer

operator or medical technician training);
(2) Provide a job placement service that offers reasonable
assurance that the applicant will be employed following
successful completion of the program; and
(3) Be limited to no more than two (2) years if training is
non-degree program.
Undergraduate A student attending either:

Program
(1) A full-time undergraduate program with a minimum of
twelve (12) credit hours per semester or six (6) credits
hours for a summer session (continuing student only);
or
(2) A part-time undergraduate program with less than
twelve (12) credit hours per semester while also
employed. Each credit hour equals one (1) hour of work
per week.
Participants in This group of applicants participates in a qualifying activity for a minimum of

Food Stamp twenty (20) hours per week and receive Food Stamps but may not be receiving
Employment/ TANF benefits.
Training
Program
TANF This group of applicants includes TANF recipients participating in a

Recipients qualifying activity for a minimum of 20 hours per week. The timeframe that
child care is requested and the parent(s) or guardian(s) activity schedule must
match. Only DHS CCSD Eligibility staff may place TANF recipients’
children in child care.

TANF Payee This group of applicants includes guardian(s) or custodian(s) who are
providing care to child who is not their natural child, receiving financial
assistance though ESA on behalf of the child and participating in a qualifying
activity for a minimum of 20 hours per week. The timeframe that child care is
requested and the guardian(s) or custodian(s)’ activity must match.
Teen or Young This group of applicants includes teen or young adult parents, under the age of
Adult Parent 26 years old, who are either: (1) enrolled and attend a middle school, high
school, or an equivalent secondary program (e.g. GED program), or college;
or (2) enrolled in verified job search, job training or work readiness program.
Children eligible for subsidized child care pursuant to this subsection shall
remain eligible during the summer if already provided during the school year
regardless of school or work status. In addition, families eligible for
subsidized child care pursuant to this subsection shall be provided a three (3)
month grace period from the date of graduation before income requirements
and any co-payment are applied.
(2) A child shall reside with parent(s) or guardian(s) who is seeking

employment or engaging in job search:
SEEKING EMPLOYMENT OR ENGAGING IN JOB SEARCH

TANF This group of applicants includes TANF recipients participating in a
Recipients qualifying activity for a minimum of 20 hours per week. The timeframe that
child care is requested and the parent(s) or guardian(s) activity schedule must
match. Only DHS CCSD Eligibility staff may place TANF recipients’
children in child care.
TANF Payee This group of applicants includes guardian(s) or custodian(s) who are
providing care to child who is not their natural child, receiving financial
assistance though ESA on behalf of the child and participating in a qualifying
activity for a minimum of 20 hours per week. This guardian(s) or
custodian(s). The timeframe that child care is requested and the guardian(s) or
custodian(s)’ activity must match.
Verified Job This group of applicants includes parent(s) and guardian(s) engaging a valid
Search job search, whether through DOES or another approved agency such as the
TANF Employment Program, Food Stamp Employment Program (FSET),
TANF Employment Provider (TEP), Office of Work Opportunity (OWO), or
an Economic Services Administration (ESA) approved job search or work
experience program.

(3) A child shall receive, or need to receive, protective services, or be
considered a vulnerable child, as defined herein:
RECEIVE, OR NEED TO RECEIVE, PROTECTIVE SERVICES,

OR ARE CONSIDERED A VULNERABLE CHILD.
Children This group of applicants includes parent(s) or guardian(s) of children who are
under under the active supervision of CFSA Child Protective Services division or
Protective under the active supervision of the Family Division of the DC Superior Court
Services due to abuse or neglect. The child may be living in the natural parent’s home or
with a third party.
Children eligible for subsidized child care pursuant to this subsection are
waived of the following eligibility requirements:
(1) Participate in a qualifying activity (e.g. training or employment);
(2) Income threshold requirements in Section 200.7. The eligibility staff
shall not calculate income to determine eligibility or co-payment.
Children This group of applicants includes families with a child under the age of 19 who
with special has a condition or characteristics that reflect a need for particular care, services
needs or treatment, most commonly physical and/or mental disabilities and/or delays
and is evidence by an IFSP or IEP.
Children eligible for child care pursuant to this subsection are:

(1) Waived of the requirements to participate in a qualifying activity (e.g.
training or employment); and
(2) Required to meet the income threshold requirements in Section 200.7.
Children This group of applicants represents children who are experiencing

Experiencing homelessness, as defined herein. Children eligible for subsidized child care
Homelessness pursuant to this subsection are waived of the following eligibility requirements:
(1) Participate in a qualifying activity (e.g. training or employment);
Upon initial eligibility determination, children eligible for subsidized child care
pursuant to this subsection shall be permitted to enroll in the subsidized child
care placement prior to completion of all required documentation and are
provided a sixty (60) calendar day grace period in which to provide full
documentation of eligibility. Provided the eligibility staff has established the
child is experiencing homelessness and the eligibility worker has completed
OSSE’s Child Care Referral Form (Appendix 5) as acceptable documentation
until the records can be provided, the child shall receive, and the provider shall
be paid for, subsidized child care during the grace period. If, after full
documentation is provided, the child experiencing homelessness is found to be
ineligible, subsidized child care services shall be terminated pursuant to Section
600.

RECEIVE, OR NEED TO RECEIVE, PROTECTIVE SERVICES,
OR ARE CONSIDERED A VULNERABLE CHILD.
Children in This group of applicants includes children who are wards of DC with a foster
Foster Care parent participating in a qualifying activity for a minimum of 20 hours per week,
or receiving some form of verifiable income.
Children eligible for subsidized child care pursuant to this subsection are
waived of the following eligibility requirements:
(1) Residence in the DC; and
Adoptive parents (transitioning from guardianship status) are included in this

group but must meet residency requirements. A three (3) month grace period is
allowed from the date of adoption before income requirements and any co-
payment are applied.
Children of This group of applicants represents adults with a disability for whom child care
Adults with is sought. The adult’s disability may be either physical or mental in nature. The
Disabilities standard for eligibility determination is that the disability prevents the adult
from providing adequate care for the child due to the debilitating aspects of the
condition or because the adult has frequent medical appointments.
Children of This group of applicants is parents/guardians engaged in an approved vocational

recipients of rehabilitation program. The Rehabilitation Services Administration (RSA),
vocational Department on Disability Services (DDS) provides a variety of support services
rehabilitation to enable disabled adults to prepare for, receive and maintain employment or
services improve life skills.
(c) Priority: Priority groups have been established for purposes of continuing to
enroll children if a waiting list is in effect and for giving first opportunity for
placement if there are more applicants than available funds. The implementing
regulations of the CCDBG Act, 45 C.F.R. § 98.46, require that the District of
Columbia shall give priority for subsidized child care services to:
(1) Children of families with very low family income;

(2) Children with special needs, including vulnerable children; and
(3) Children experiencing homelessness.
Accordingly, the priority and non-priority groups in the DC are:

Priority Groups Non-Priority Groups
(1) Children of families with very low family (1) Children of families with income
income, which includes the following groups: above one-hundred and thirty
 Participants in the Food Stamp percent (130%) of the FPL.
Employment/Training Program
 TANF recipients
 TANF Payee;
 Working parent(s) or guardian(s)
 Parent(s) or guardian(s) in job training or
undergraduate programs
 Parent(s) or guardian(s) in job search
 Teen Parent(s)
(2) Children with special needs, and vulnerable
children which includes the following
groups:
 Children in foster care
 Children under Protective Services
 Children of Adults with Disabilities
 Children of recipients of vocational
rehabilitation services
(3) Children experiencing homelessness.
200.7 ELIGIBILITY REQUIREMENT: DOES THE FAMILY’S INCOME EXCEED

THE MAXIMUM INCOME THRESHOLD?
In order to be eligible for subsidized care, the child shall reside with a family whose:
(1) Annual gross family income does not exceed two hundred and fifty
percent (250%) of the federal poverty guideline (FPL) or eighty five
percent (85%) of the DC median income (SMI) for a family of the same
size, whichever is lower, as provided in Appendix 6: Maximum Income
Guidelines for Subsidized Child Care; and
(2) Family assets do not exceed $1,000,000.2
In order to determine if an applicant is income eligible, the eligibility staff shall first
determine the family size; and second determine the family’s gross annual income.
(a) Determining Family Size: Family size is the number of family members living in
the same household, which shall:
2
Families who left the program for other reasons may also reapply and be considered if the gross annual income is
below 300% of FPL or 85% of the most current SMI. Previous participation must be verified through OSSE DEL
MIS. See Section 500.4 of this Policy Manual.

(1) Include parents requesting child care services including:
(A) Biological parents;
(B) Adoptive parents;
(C) Stepparents, even if the stepparent has not legally adopted the
children; or
(D) Adult(s) standing in loco parentis for children under age 18

because they have assumed the responsibility for the day-to-day
care and supervision of the child; and
(2) Include all the parents’ dependent children under age 18 or up to 21 years
of age if still attending school and school attendance is verified, including:
(A) Both an adult’s natural children and other children for whom that
adult is a guardian; or
(B) Foster children;
(3) Not include the following:
(A) Other children who live at the same address but are dependent on
another adult; or
(B) Any other adults, such as grandparent(s), aunts or uncles.
(4) Any child for whom legal relationship documentation has not been
provided may not receive subsidized child care nor be countable as a
dependent. (See acceptable documentation in Section 300).
(b) Determining Annual Gross Family Income: The eligibility staff shall then
determine the gross annual family income, taking into account any allowable
deductions or irregular fluctuations in earning, and ensuring that temporary
increases in income, including temporary increases that result in monthly income
exceeding eighty five percent (85%) of the DC median income (SMI) do not
affect eligibility or parent share of cost. The exact amount of annual gross family
income is compiled from all sources of income expected to be included as
discussed below:
(1) Countable Income (Included). Countable income is the portion of the

annual gross family income of the family that includes:

(A) Gross salaries or wages of one or both parent(s) or guardian(s),
including regularly received commissions, tips, and overtime (see
discussion below);
(B) Net income from self-employment (business expenses shall be

deducted from gross receipts);
(C) Other income of parent(s) or guardian(s) such as Social Security

and Veterans Benefits;
(D) Income of children receiving subsidized care such as child support

or Social Security Income;
(E) Unemployment Compensation;
(F) Workers Compensation;
(G) Alimony; and
(H) The portion of an educational grant that is specifically designated

for living expenses
(2) Seasonal Employment. If applicants are employed by a school system,

their income would be based on a 10 month calculation.
(3) Irregular Fluctuations. Temporary increases in income shall not affect

eligibility or family co-payments, including monthly income fluctuations
that show temporary increases, which if considered in isolation, may
incorrectly indicate that a family is above the threshold of 85 percent of
SMI, when in actuality their annual income remains at or below the
maximum income level allowable based on family size as provided in
Appendix 6: Maximum Income Guidelines for Subsidized Child Care. In
these situations, an eligibility staff may seek further documentation such as
an earnings statement that is most representative of the family’s income
rather than the most recent statement.
(4) Overtime. Overtime is countable as part of the applicant’s income if it is

worked on a regular basis. As a general rule, if at least one (1) of the two
(2) pay statements presented reflect overtime, the salary must be
calculated to include the overtime by adding the total gross family income
for the two (2) pay statements and finding the average [dividing by two
(2)], then converting to an annual figure. However, if the applicant
declares that overtime is not regularly worked, the applicant is given the
opportunity to provide proof through documentation set forth in Section
300.

(5) Exempt Income. The following income shall not be included in
determining gross annual family income:
(A) TANF benefits;
(B) Supplemental Security Income (S.S.I.);
(C) Lump sum child support payments;
(D) In-kind income - something of value other than cash, (i.e. food
stamps, free medical care or free or subsidized rent);
(E) Low Income Energy Assistance;
(F) Gifts;
(G) Loans and grants for scholarships that do not allow their use for
living costs;
(H) Income of others in the household who do not have financial

responsibility for the child;
(I) Tax Refunds;
(J) Subsidized adoption and foster care payments;
(K) Stipends (such as for work experience programs);
(L) Lump sum inheritance or insurance payments;
(M) Capital gains; and
(N) Assets such as real estate, bank accounts savings, stocks and
bonds.

(6) Income Computation. Income shall be computed using the annual gross
family income total arrived at by adding up all sources that can be
countable and multiplying by the applicable number of pay periods. All
income is converted to a yearly figure. Figures are multiplied as follows:
Amount Per Pay # of Pay Annual

Period Periods Amount
Weekly pay x 52 Weeks = $ _______
Bi-weekly pay x 26 Weeks = $ _______
Bi-monthly pay
x 24 Weeks = $ _______
(twice monthly)
Monthly pay x 12 Months = $ _______
Seasonal employees (10 month employment) should be calculated as follows:
Amount Per Pay # of Pay Annual

Period Periods Amount
Weekly pay x 44 Weeks = $ _______
Bi-weekly pay x 22 Weeks = $ _______
Bi-monthly pay
x 20 Weeks = $ _______
(twice monthly)
Monthly pay x 10 Months = $ _______
See Appendix 7: Calculation of Parent’s Income Form which is used in

determining calculation of parent(s) or guardian(s) income.

SECTION 300
ELIGIBILITY DETERMINATION AND PLACEMENT PROCESS
The process to determine a child’s eligibility for subsidized care in DC shall include: (1) a pre-
screening; (2) an intake interview; and (3) submission of supporting documentation.3
Children experiencing homelessness, under TANF, Child Protective Services, the Foster Care
system, the DC Court system or the Rehabilitation Services Agency shall only apply through
DHS CCSD, not at a Level II child development facility.
Once a child is determined as eligible to receive subsidized care in DC, the eligibility staff shall:
(1) determine placement; and (2) issue an admission form to the parent(s) or guardian(s).
300.1 PRE-SCREENING
The eligibility staff shall pre-screen all prospective applicants for potential eligibility.
Factors discussed must include the following:
(a) The application process;
(b) An outline of the six conditions of eligibility: a child’s age, a valid legal
relationship to the child; a child’s status as a citizen or legal immigrant, residency
in the District of Columbia, need, and gross annual income does not exceed the
maximum income for subsidized care;
(c) Family’s need for care, including time, type, and any special needs; and
(d) What information and verification are necessary to determine eligibility, including
required supporting documentation necessary to complete an application and a
government issued photo identification.
The eligibility staff shall schedule an appointment for intake for any applicant wishing to
pursue an application for eligibility determination.
300.2 INTAKE INTERVIEW
The eligibility staff shall conduct a personal interview with the applicant at intake and
with the recipient at redetermination of eligibility, accordingly:
3
A DHS supervisor or manager must review and verify eligibility for any DHS staff requesting eligibility
determination through DHS/CCSD.

(a) The eligibility staff shall ensure assistance is provided as needed for reading or
interpreting all information during the application process including
understanding that parent(s) or guardian(s) signature is considered as certification
that all information provided is correct and accurate under penalty of law.
(b) The eligibility staff shall allot a minimum of forty five (45) minutes for the initial
interview.
(c) During the interview, the eligibility staff shall:
(1) Explain DC’s subsidized child care program, eligibility requirements and
the applicant’s rights and responsibilities as listed on the Application for
Subsidized Child Care Services in Appendix 3;
(2) Verify the applicant’s identity by reviewing their government issued photo
identification, which may include a DC driver’s license or a passport. But
note, eligibility staff shall accept an application from a representative of a
parent or guardian who is physically unable to come to the office when
accompanied by a letter authorizing a different signatory. The application
is expected to be completely filled out and must be signed by the parent(s)
or guardian(s) with all the necessary supporting documentation attached;
(3) Explain that the application is not complete until the application form is
filled out and all supporting documents have been received as required;
(4) Ensure the Application for Subsidized Child Care Services in Appendix 3
is completed, signed and dated;
(5) Review documentation submitted by the applicant, which includes but is

not limited to, resolving any issues related to unclear or incomplete
information, and authenticating all documents received during the visit;
(6) Record key eligibility factors in the MIS;
(7) Place a copy of all documentation in the paper case record;
(8) Provide a copy of all relevant application documents to the parent(s) or

guardian(s) for their records;
(9) Inform the applicant of the types of child care available; and
(10) Discuss the needs of the family including:
(A) The type of child care needed (i.e. center based, family home,
relative home, or in-home);

(B) When child care is needed (i.e. full-day, before and after school,
non-traditional hours including nights and weekends); and
(C) Possible special needs or special health care needs of the child.
(d) Exceptions to the interview requirement are made when referrals for which all
transactions may be handled by the referring staff member. These include
applicants under the foster care, child protective services programs and TANF
recipients.
300.3 SUPPORTING DOCUMENTATION
(a) In addition to the supporting documentation below, the parent(s) or guardian(s)

shall provide a valid government issued photo identification, which may include a
DC driver’s license or a passport, to the eligibility staff to verify the applicant’s
identity.
(b) The eligibility staff shall collect the supporting documentation to establish the
applicant’s eligibility factors. The eligibility staff shall review all required
documents closely to ensure they are authentic and that they match the applicant’s
verbal statements and application. Unless otherwise noted, all eligibility
documents shall be submitted and signed by the applicant and approved by the
eligibility staff before a child is placed in a subsidized slot. All documentation
must be original documents or a copy certified by the issuing agency unless an
exception is noted. Acceptable supporting documentation for each eligibility
factor is provided in the table below:
Eligibility Factor Acceptable Documentation

(1) Child’s Age Acceptable documents for verification of a child’s age includes one
of the following:
(1) A full size original birth certificate. The birth certificate must
include the name of the parent(s) or guardian(s) requesting
services;
(2) A birth certificate in a non-English language with a certified
translation; or
(3) Hospital record of birth, only for an infant under six (6)
months old signed by a licensed physician or licensed health
care practitioner. The official birth certificate must be
supplied within 30 days of the date of application.
(2) Legal Acceptable documents for verification of the legal relationship

Relationship between a child and the parent(s) or guardian(s) includes one of the
following:
(1) A full size original birth certificate. The birth certificate must
include the name of the parent(s) or guardian(s) requesting
services;

(2) A birth certificate in a non-English language with a certified
translation;
(3) Hospital record of birth, only for an infant under six (6)
months old signed by a licensed physician or licensed health
care practitioner. The official birth certificate must be
supplied within 30 days of the date of application;
(4) Current and valid Adoption or Custody Order with a
finalization date, issued by a court. If not a final order, the
most recent order that is currently in effect. Custody may not
be established simply by a parent(s) or guardian(s) preparing
a notarized letter turning over the care of a child to another
person;
(5) A referral from an authorized DC government agency or its
vendor that verifies relationship has been established (such as
a referral from the DC Superior Court, Family Division, the
Economic Securities Administration (ESA), the Child and
Family Services Agency or from one of the agencies’
vendors); or
(6) Documentation from a federal or DC entity proving the
applicant’s relationship to the child, including receiving
benefits on behalf of the child (such as an admission form
from DHS, documentation of payment from TANF including
child’s name on the statement, a letter verifying Social
Security, Veterans’ Benefits, child support, or any other
benefit received by the applicant on behalf of a child). For
documentation that is more than 30 days old, the applicant
must also supply a copy of the current benefit check. See
Appendix 5: Child Care Referral Form.
(3) Citizen or Legal Acceptable documents for verification of a child’s citizenship or

Status legal status includes one of the following:
(1) Birth certificate showing that the child was born in the
United States or to parents holding U.S. citizenship;
(2) Lawful Permanent Residency Document (formerly known as
the “green card”);
(3) Immigration and Naturalization Service (INS) documentation
or other official identification verifying the child’s
citizenship or immigration status;
(4) A visa such as the H-2 visa allowing presence in this country
for the time period during which child care is to be provided;
(5) Form I-94 to show entry as a refugee;
(6) Form I-94 showing grant of asylum;
(7) Order from an Immigration Judge showing deportation
withheld;
(8) Form I-94 showing admission under conditional entry;

(9) An approved or pending petition of a battered spouse or
child; or
(10) A formal referral from one of the following sources:
(A) Temporary Assistance for Needy Families (TANF);
(B) Food Stamp Employment/Training Program;
(4) Residency The eligibility staff shall confirm that all documentation validating
residence is in the applicant’s name; is an original document and, if
applicable, dated no more than 30 days prior to the date eligibility is
being established. Acceptable documents for verification of DC
residency includes one of the following:
(1) Current official rent receipt on the company form or
letterhead including the name of the applicant, current
address, name of the landlord or rental agency, and date of
receipt (no more than 30 days old);
(2) Evidence of home ownership such as a mortgage payment
statement including the applicants name and current address
(no more than 30 days old);
(3) Lease, mortgage, or housing subsidy document showing
applicant’s name and address (no more than 30 days old);
(4) Original utility bill (residential telephone, gas, electric, water
or sewer bill) showing applicant’s name and current address
(no more than 30 days old). Cellular telephone bills are not
accepted. Cable bills are unacceptable unless the home
telephone service is included on the bill;
(5) A notarized letter with original seal (indentation) signed by
the landlord, homeowner, or person with whom the applicant
resides stating that the applicant and children (include
names) live with the writer at the stated address. The
notarized letter must be dated within 30 days of the
eligibility determination date and must be accompanied by
two other current, original pieces of mail dated within 30
days and showing the applicant’s name and address. One
pay stub with current address may be included among these
supporting documents;
(6) E-bills for utilities (telephone, electric, water, sewer or gas)
showing applicant name and current address along with two
pieces of mail as described directly above;
(7) Referrals no more than 30 days old from an authorized DC
agency such as the Child and Family Services Agency
(Foster Care or Child Protective Services), DC Superior
Court, or the TANF program;
(8) Documentation no more than 30 days old that the applicant is
currently receiving TANF, Food Stamp or Medicaid benefits;
or

(9) A pay stub showing a DC address and DC withholding taxes
issued in the last thirty (30) days.
(5) Need
Classification
Working parent Acceptable documentation for verification of employment includes
one of the following:
(1) Two (2) most recent consecutive pay statements verifying
employment including the name of the employee, social security
number (or employee identification number or its equivalent), the
number of hours worked, wages and salary information for the
pay period on the statement. At least one statement must be
dated no more than 30 days prior to the date of
application/eligibility determination;
(2) An original letter from the employer on business letterhead with
company name identified. The supervisor or manager must sign
and date the letter. The letter must include the applicant’s full
name and address, start date of employment, gross wages or
salary, work schedule (hours and days). The letter must be dated
no more than 30 days prior to the date of application/eligibility
determination. A letter is acceptable only in a case where pay
statement is not normally given such as in domestic employment.
A letter is also acceptable for an employee in a new job. The
new employee must submit an original pay statement within 30
days of the application and must submit one (1) more pay
statements to complete the requirement for two (2) original pay
statements. A letter is also acceptable for documentation of leave
pursuant to the District of Columbia Family Medical Leave Act
of 1990, effective October 3, 1990 (D.C. Law 8-181; D.C.
Official Code §§ 32-501 et seq.);
(3) Referral from ESA or one of its vendors who provide training
and placement;
(4) Confirmation of job search or job training from DOES, TANF
Employment Program, Food Stamp Employment Training
(FSET), TANF Employment Provider (TEP), Office of Work
Opportunity (OWO), or an ESA-approved job search or work
experience program; or
(5) Self-Employment records: Self-employed persons must supply
the same documents maintained for income and tax purposes,
including but not limited to:
(A) Valid DC business license;
(B) Daily log record (manifest) of an operator of a public vehicle-
for-hire for a minimum of four (4) weeks;
(C) Barber and cosmetology license, records of booth rental and
equipment lease or appointment schedules and daily sales
records with recent dates; or

(D) Street Vendor’s license, record of supply purchases and daily
sales, and rental equipment receipts with recent dates.
Job training Acceptable documentation for verification of participation in a

training program includes a letter from the training program
identifying the student by name that confirms the applicant’s current
attendance and progress/status in the program (no more than 30 days
old).
Education Acceptable documentation for verification of participation in an

program undergraduate program includes one of the following:
(1) A schedule of classes from the registrar identifying the
student and indicating registration has been paid;
(2) A student identification card with a valid semester sticker or
symbol for the current semester; or
(3) A receipt from the college stamped “paid” for the current
semester.
Participants in Acceptable documentation for verification of participation in Food

Food Stamp Stamp Employment/Training Program includes one of the following:
Employment/ (1) A referral from the ESA verifying Food Stamp status (referral
Training Program doubles as documentation for residency and relationship) See
Appendix 5: Child Care Referral Form; or
(2) Verification of employment (refer to working parent(s) or
guardian(s) verification requirements).
TANF Recipient Acceptable documentation for verification of receipt of TANF

benefits includes one of the following:
(1) A current pay statement verifying employment;
(2) Referral from ESA or one of its vendors who provide training
and placement;
(3) Confirmation of job search or job training from DOES;
(4) Confirmation of work experience program from ESA; or
(5) Effective October 1, 2016, evidence of successful completion
and approval of the applicant’s Individual Responsibility
Plan. The Individual Responsibility Plan (IRP) is defined as
“a written agreement developed jointly by the applicant and
DHS or a DHS Provider that acts as the applicant’s roadmap
to securing employment and becoming self-sufficient. The
IRP outlines specific steps that the customer agrees and
commits to take in order to address and remove barriers, and
find and retain employment.

Acceptable documentation for verification of receipt of TANF Payee
benefits includes documentation of receipt of the TANF check for
TANF Payee the child, including the child’s name on the statement; and one of the
following:
(1) A current pay statement verifying employment; or
(2) Confirmation of job search or job training from DOES,
TANF Employment Program, Food Stamp Employment
Training (FSET), TANF Employment Provider (TEP), Office
of Work Opportunity (OWO), or an ESA-approved job search
or work experience program.
Teen or Young Acceptable documentation for verification of enrollment and
Adult Parent attendance includes one of the following:
(1) Written documentation of enrollment including student’s
name, address, social security number or student ID number
with date of enrollment; or
(2) A printout of the student’s class schedule if application is
during the start of a new school year or a letter from a school
official if application taken any other time of the school year.
Documentation must include the student’s name, address,
social security number or student ID number signed and dated
by an appropriate official. Teen or young adult parent(s) who
submit an application for subsidized child care in the summer
or in beginning of the school year have thirty (30) days from
the date of the application to submit documentation for proof
of attendance.
Children under Acceptable documentation for verification of the receipt of

Protective Services protective services includes one of the following:
(1) Referral from either a Foster Care worker or a CFSA vendor.
See Appendix 5: Child Care Referral Form; or
(2) Referral via memorandum from the child’s case worker.
Children with Acceptable documentation for verification of classification as child

special needs with special needs includes one of the following:
(1) A copy of the child’s Individualized Education Plan (IEP) or
Individualized Family Service Plan (IFSP) that is no more
than one (1) year old;
(2) A copy of the 504 Accommodation Plan, no more than one
(1) year old;
(3) A referral from DC’s Early Intervention Program (DC EIP)
identifying eligibility for early intervention services;
(4) A copy of the results of a standardized assessment instrument,
a developmental inventory or behavioral checklist confirming
disability;
(5) Written documentation from a certified/licensed therapist

certifying disability;
(6) Written documentation from a valid intervention program the
child is attending certifying disability or special health care
need; or
(7) Written documentation from a licensed health practitioner
certifying disability or special health care need.
Children Acceptable documentation for verification of homelessness includes

Experiencing OSSE’s Child Care Referral Form, completed by the eligibility
Homelessness worker at the Virginia Williams Resource Center. See Appendix 5.
Children in Foster Acceptable documentation for verification of foster care includes

Care one of the following documents:
(1) A current pay statement verifying employment;
(2) Confirmation of job search or job training from DOES,
TANF Employment Program, Food Stamp Employment
Training (FSET), TANF Employment Provider (TEP), Office
of Work Opportunity (OWO), or an ESA approved job search
or work experience program; or
(3) Documentation the applicant receives at the time of
application some form of verifiable income, including Social
Security benefits, Veterans’ benefits, or disability benefits.
Income received exclusively for participating in the foster
care program shall not count toward the form of verifiable
income required in this subsection.
Children of Adults Acceptable documentation for verification of classification as an

with Disabilities adult with disabilities includes one of the following:
(1) A physician’s written statement on official letterhead that
specifically recommends child care for the adult with the
disability; or
(2) A referral from the Developmental Disabilities
Administration (DDA), Department on Disability Services
(DDS) substantiating the effects of the adult’s condition on
daily functioning in connection to the child.
Children of Acceptable documentation for verification of classification as a

Recipients of recipient of vocational rehabilitation services includes one of the
vocational following:
rehabilitation (1) A referral from RSA via letter or memorandum; or
services (2) A referral from RSA utilizing the standard Child Care
Referral form.
(6) Income Acceptable documentation to verify income, includes any of the

Threshold following:

(1) Two (2) most recent consecutive pay statements verifying
employment including the name of the employee, social
security number (or employee identification number or its
equivalent), the number of hours worked, wages and salary
information for the pay period on the statement. At least one
statement must be dated no more than 30 days prior to the
date of application/eligibility determination;
(2) An original letter from the employer on business letterhead
with company name identified. The supervisor or manager
must sign and date the letter. The letter must include the
applicant’s full name and address, start date of employment,
gross wages or salary, work schedule (hours and days). The
letter must be dated no more than 30 days prior to the date of
application/eligibility determination. A letter is acceptable
only in a case where pay statement is not normally given
such as in domestic employment. A letter is also acceptable
for an employee in a new job. The new employee must
submit an original pay statement within 30 days of the
application and must submit one (1) more pay statements to
complete the requirement for two (2) original pay statements.
A letter is acceptable for documentation of leave pursuant to
the District of Columbia Family Medical Leave Act of 1990,
effective October 3, 1990 (D.C. Law 8-181; D.C. Official
Code §§ 32-501 et seq.);
(3) Payment receipts for services rendered where the type of
employment may not generate an earnings statement or pay
stub, such as but not limited to restaurant server,
cosmetologist, or an operator of a public vehicle-for-hire.
Overtime Acceptable documentation to verify that overtime is not regularly

worked, includes any of the following:
(1) Two (2) or more additional pay statements provided from the
preceding three (3) months. If they document several pay
periods without overtime, the salary shall be computed
without overtime hours;
(2) A letter from the employer may be provided to specify the
applicant’s projected overtime schedule (i.e. whether it is
seasonal or otherwise temporary) in which case overtime
shall not be countable; or
(3) The year-to-date salary may be used to project the applicant’s
annual pay and thus help to determine whether calculations
are correct.
Deductions Acceptable documentation of the expenses that may be deducted for

children with special needs include:

(1) Monthly statements reflecting cited expenses;
(2) Insurance claims indicating covered medical expenses and
reimbursed amounts; or
(3) If expenses are listed as income tax deductions, a certified
copy of the previous year’s DC D-40 income tax statement is
acceptable.
(c) The eligibility staff shall inform applicants they have (30) days from the date the
applicant submits the Application to secure and submit all supporting
documentation. If the required documentation has not been provided after (30)
days, the application shall be null and void.
300.4 DENIAL OF APPLICATION

(a) The eligibility staff shall deny approval of an application when:
(1) The applicant does not satisfy the eligibility requirements for relationship, the
child’s citizenship or immigration status, residency, need and/or income;
(2) The applicant has failed to provide all required documentation for the
establishment of eligibility within 30 days of the date of the application;
(3) The applicant’s information is found to be false; or
(4) Funds are not available for placement for a family in a non-priority category.
In this case, the applicant’s name may be added to a waiting list.
(b) When the application for subsidized care is denied, the eligibility staff shall give
written notice on the application, including:
(1) The decision;
(2) The basis for the decision, including legal citations where appropriate;
(3) Explanation of the applicant’s right to an Administrative Hearing; and
(4) The eligibility staff member’s signature and the date.

The eligibility staff shall provide information and referral services pertaining to other
government and community programs and services to address other needs of the
applicant. This may include DC’s 311 information service.
The case record for a denied or voided application, including any documentation related
to the case, must be maintained for ninety (90) days in case the applicant appeals the
decision. Copies of all documents must be secured in the file before the termination
notice is given.
300.5 PLACEMENT
When a child and family has been determined to meet all eligibility criteria, the eligibility
staff must then work with the family to determine what type of child care arrangement
best meets the needs of the child and family. The circumstances that justify the need for
child care services and the plan of care must be documented in the case record.
(a) Parent(s) or Guardian(s) Choice: The eligibility staff must assure parent(s) or
guardian(s) choice by explaining the various placement options, which include
licensed child care centers, licensed home providers, and relative and in-home
care. The applicant may also consult with OSSE DEL’s Child Care Resource and
Referral Service for provider information.
Applicants requesting subsidized placement in care centers and licensed child care
homes must select from the providers that have agreements with OSSE. The
parent(s) or guardian(s) shall be encouraged to visit the selected facility before the
child placement occurs.
(b) Placement at a Level II Child Development Facility: For a Level II placement

selection, if there is an age appropriate vacancy at that particular center, the
eligibility staff shall provide the applicant with the facility’s parent(s) or
guardian(s) manual and explain the program’s policies, such as hours of operation
and parent(s) or guardian(s) responsibilities.
(c) Placement in Relative or In-Home Care: The DHS CCSD eligibility staff
member shall only permit the use of in-home care as a last resort, when the
applicant has made attempts to enroll the child(ren) at three (3) separate licensed
facilities. An exception may be made by the eligibility staff for any applicant who
works non-traditional hours for which in-home care is the only possible child care
arrangement. The reason for in-home care must be documented in the case file.
The eligibility staff member shall complete the eligibility determination process
and then notify OSSE DEL of the need for a formal agreement as a result of in-
home care placement. OSSE DEL is then responsible for ensuring a signed
formal agreement is executed with the proposed provider for relative or in-home
care arrangements.

A relative child care home provider may reside in the neighboring jurisdiction of
Maryland or Virginia.
(d) Placement Changes: Eligibility staff shall permit a change in placement after a
written statement is received from the applicant explaining the reason for the
requested transfer.
300.6 ADMISSION FORM
When a family has been determined to meet all eligibility criteria and placement has been
made, the eligibility staff shall issue an admission form to the parent(s) or guardian(s)
with instructions to have it completed by the provider and returned to the DHS CCSD in
order for the provider to be paid for child care services. See Appendix 4: Child Care
Admission Form. The provider must enter the date the child started at the facility and sign
and date the form. The provider shall return the admission form via email to the Intake
and Continuing Services Unit, DHS CCSD within 24 hours after the child is enrolled at
the facility.

SECTION 400
FAMILY CO-PAYMENT
The eligibility staff must determine what, if any, contribution the applicant will be expected to
make toward the cost of care. Co-payments are made by the parent(s) or guardian(s), unless
exempted below, toward the cost of child care services. These payments are assessed for each
child and are paid directly to the provider.
In order to determine the co-payment, the eligibility staff shall (1) determine if the applicant is
exempt from co-payment; (2) if not exempt, determine the family size; and (2) determine the
family’s gross annual income.
400.1 CO-PAYMENT REQUIREMENTS BASED ON NEED ELIGIBILITY

CATEGORY
The eligibility staff must first identify the need eligibility category to be used for the
applicant. Some categories will exempt the applicant from any payment while others
require consideration of annual adjusted gross family income to determine the co-
payment.
(a) Applicants exempt from co-payment include:
(1) TANF recipients in countable activities other than employment;
(2) TANF payees in countable activities;
(3) TANF parent(s) or guardian(s) with physical or mental, disabilities;
(4) Unemployed parent(s) or guardian(s) receiving vocational rehabilitation

services;
(5) Children receiving Child Protective Services;
(6) Children in foster care;
(7) Children experiencing homelessness;
(8) Teen or young adult parent(s) in junior and senior high school; and

(9) Working parents/guardians or benefit recipients with income levels falling
below 50% of the FPL.
(b) The eligibility staff shall allow adoptive parent(s) or guardian(s) (foster parent(s)
who finalizes an adoption) three (3) months with no co-payment from the
effective date of adoption before beginning co-payments if payment requirement
has been established. Adoption subsidy funding shall not be used as part of the
countable income.
(c) The eligibility staff shall consider the possibility of a co-payment for the
following eligibility categories:
(1) Participants in the Food Stamp employment/training program;
(2) Adoptive parents [after three (3) months grace period];
(3) Children with disabilities;
(4) Working parent(s) or guardian(s);
(5) Recipient of vocational rehabilitation services; or
(6) Parent(s) or guardian(s) in structured job search, undergraduate program

or training.
400.2 DETERMINATION OF FAMILY SIZE
The eligibility staff shall determine the number of family members to be considered in
the family size using the guidelines set forth in Section 200.7(a).
400.3 ADJUSTED ANNUAL GROSS FAMILY INCOME DETERMINATION
The adjusted annual gross family income is the basis for determining co-payment. The
adjusted annual gross family income is determined by subtracting applicable deductions
from the annual gross family income, accordingly:
(a) The eligibility staff shall determine the annual gross family income using the
guidelines set forth in Section 200.7(b).

(b) From the annual gross family income, the eligibility staff shall consider the
following three (3) possible deductions before arriving at the adjusted annual
gross family income:
(1) The costs of child care services or after school fees for any sibling of the
child(ren) to be placed for whom the parent(s) or guardian(s) pays the full
cost of a private child care during the applicant’s scope of work hours.
Documentation from the caretaker must be provided. This does not
apply to fees paid for a child in another DEL subsidized program. It
also does not apply to private school tuition paid by the applicant.
(2) Child support payments made by one (1) of the parent(s) or guardian(s) in
the same household as the eligible child to support child(ren) in another
household. Proof of the deduction is required (evidence of withdrawal
directly from the paycheck or evidence of regular payments based on a
court order or agreement).
(3) Deductions related to children with disabilities including Supplemental

Security income (SSI); medical or therapeutic expenses for the child (i.e.
medical bills, therapy costs paid by the family, medication costs, braces or
other appliances); assistive technology device costs and/or disability
related transportation costs. All expenses require verification through the
monthly statement identifying paid expenses.
400.4 APPLICATION OF THE CO-PAYMENT SCALE (SLIDING FEE SCALE)
The eligibility staff shall use the adjusted annual gross family income and family size to
determine the applicable amount of the co-payment using the Co-Payment Scale. See
Appendix 8: 2009 Sliding Fee Scale or 5A DCMR Chapter 2. The eligibility staff shall
apply the co-payment scale accordingly:
(a) The line with salary that either matches or is the next largest amount on
the scale for the adjusted annual gross family income must be matched
with family size to determine level of co-payment.
(b) A family size of one (1) would apply to a child in a guardianship situation
where the fee is based solely on the child’s income.
(c) The co-payment scale is based only on income and family size. It is not
based on type of placement (i.e. child care center, family child care home).
(d) The co-payment scale features columns for full-time and part-time
enrollment (first child-youngest and second child-older). There is no
additional co-payment required when there are more than two (2) children.

(e) The eligibility staff shall consider the impact of any non-traditional child
care options which may result in a child being authorized for more than
one type of care (for example, “full day” plus “non-traditional part-time”).
Care may be provided at the same facility or at different facilities. In
either case, the parent(s) or guardian(s) will pay only one fee, based on the
chart, for any one child. Application of the fee will apply to the service
with the largest number of hours only (in this example, the “full day”
placement). No fee will be assigned to the second placement.
400.5 CO-PAYMENT FOR MULTIPLE CHILDREN
The eligibility staff shall consider applying the co-payment to the two (2) youngest
children receiving subsidy when there are multiple children in one family.
400.6 CHANGE IN CO-PAYMENT
The eligibility staff shall monitor any change in parent(s) or guardian(s) status throughout
the period of eligibility to ensure the co-payment is correct at all times. Co-payments may
not be increased during a twelve (12) month eligibility period. However,
redeterminations to decrease co-payment may be necessary in any one of the following
instances:
(a) Change in qualifying activity;
(b) Change in income (decrease); or
(c) Change in family size (increase).
The eligibility staff shall complete an analysis/computation to determine if the co-

payment fee will decrease. If there is a decrease in co-payment, the Parent Fee Change
(Appendix 9) must be completed and signed by the parent(s) or guardian(s).
400.7 PAYMENTS TO PROVIDERS
(a) The details for responsibility of co-payment by the family are based solely on the
agreement between the provider and family and must be in accordance with the
written payment policy of the provider. Receipts shall be given to the parent(s) or
guardian(s) by the provider for all co-payments received. The child care facility
may terminate a child’s placement, following two (2) weeks’ notice, when
payment is in arrears (payment has not been made).

(b) DC shall not be responsible for the collection of the parent(s) or guardian(s) fee or
co-payment.
(c) If a child’s placement is terminated due to failure to pay co-payment, the

eligibility staff shall determine if a redetermination of co-payment is necessary, as
set forth in Section 400.6.
(d) DC’s responsibility to serve eligible families requires new placement for a child
even when the family owes money to a previous provider.

SECTION 500
REDETERMINATION OF ELIGIBILITY
Redetermination of a child’s eligibility for the DC’s child care subsidy program shall be
completed by the eligibility staff no sooner than 12 months following the initial determination or
most recent redetermination. The due date for each review is entered in OSSE DEL MIS during
the initial visit and again with each redetermination appointment. The eligibility staff will be
expected to monitor the MIS and retrieve this information routinely to inform parent(s) or
guardian(s) of the need for review, the details for scheduling an appointment and the documents
required.
The DHS CCSD shall maintain responsibility for cases where children are placed in more than
one facility, even if one or more of the facilities is a Level II provider. The Level II eligibility
staff shall re-determine eligibility for all other children enrolled in their Level II slots.
500.1 ELIGIBILITY PERIOD
Once a child is determined as eligible for receiving child care subsidy assistance, the family or
individual will be considered to meet all eligibility requirements for such assistance and will
receive assistance for not less than 12 months before re-determining eligibility.
(a) A child shall remain eligible for the DC’s child care subsidy program throughout
the 12 month eligibility period regardless of:
(1) A change in gross annual family income, if the gross annual family
income does not exceed 300% of the Federal Poverty Level or 85 percent
of the State median income for a family of the same size;
(2) Parental Leave. For applicants already receiving child care services, child
care may be continued during a parent(s) or guardian(s)’ period of parental
leave, for not less than 12 months from the last date the applicant was
determined as eligible for receiving child care subsidy assistance. The
applicant’s income will determine whether the applicant pays a fee during
parental leave. Child care for parental leave is not provided to a new
applicant.
(3) A temporary change, as defined herein, in the child’s parent(s) or

guardian(s) ongoing status.
(4) A change in the child’s age, including turning 13 during the eligibility
period; and
(5) Any change in residency within the District of Columbia.

(b) Unscheduled Redeterminations. A child’s eligibility for the DC’s child care
subsidy program shall be re-determined during the 12 month eligibility period in
the following situations:
(1) Any change in residency outside of the District of Columbia;
(2) Non-temporary change, as defined herein; or
(3) A change in income, if the family’s income exceeds 85 percent of the

State median income for a family of the same size.
(c) Applicants shall report any of the changes leading to an unscheduled

redetermination to their eligibility staff within ten (10) calendar days of the
change.
(d) Applicants are not required to unduly disrupt their education, training, or
employment in order to complete the eligibility redetermination process.
(e) Eligibility staff are responsible for following up on any information that comes to
their attention that may have a bearing on a child’s eligibility for services. An
eligibility review may be requested by the agency at any time when a change of
status is reported or suspected. If eligibility is affected, necessary action is
expected to be taken promptly after written notice is given. An eligibility review
may also be scheduled early if a request for a placement change or other change is
made. Once the “off schedule” review is completed, the next review date shall be
adjusted to occur in 12 months’ time.
The table below provides examples of the impact of temporary and non-temporary
changes on a child’s eligibility and also reviews other potential eligibility scenarios. The
situations demonstrated in the table are just examples and shall not be used as a
basis for eligibility determinations.
Non-Temporary and Temporary Change Scenarios

If: Then:
Parent is absent from work for two weeks to This is a temporary change. Child remains
care for sick grandma. eligible through the end of the twelve (12)
month eligibility period.
Parent is absent from work for three weeks to This is a temporary change. Child remains
care for sick child. eligible through the end of the twelve (12)
Parent is a custodian at an elementary school This is a temporary change. Child remains
and the school is closed for the summer. eligible through the end of the twelve (12)
Parent is a UDC student and not attending This is a temporary change. Child remains
classes during the summer break. eligible through the end of the twelve (12)

Non-Temporary and Temporary Change Scenarios (continued)
If: Then:
Parent is participating in a training program This is a temporary change. Child remains
and the program is on a break for two weeks eligible through the end of the twelve (12)
during the holidays. month eligibility period.
Parent was working 20 hours week at Home This is a temporary change. Child remains
Depot but his/her hours were cut to 15 hours a eligible through the end of the twelve (12)
week. month eligibility period.
Parent lost job 90 days ago and is no longer This is a non-temporary change. Child is no
working. longer eligible. Termination Letter issued on
91st day without job. Child may continue to
receive subsidy for 90 days from the date the
Termination Letter was issued.
Parent’s training program ended 90 days ago This is a non-temporary change. Child is no
and parent has not secured a new job or longer eligible. Termination Letter issued on
entered a training program. 91st day that parent is not participating in
training program. Child continues to receive
subsidy for 90 days from the date the
Parent lost job 60 days ago and got a new job. This is a temporary change. Child remains
eligible through the end of the twelve (12)
Parent receives a small raise and is now Child remains eligible through the end of the
making more money than they were making at twelve (12) month eligibility period.
the eligibility determination but income does
not exceed 300 percent of the Federal Poverty
Level (FPL).
Parent receives a large raise and income Child is no longer eligible. Termination Letter
exceeds 300 percent FPL. shall be issued but child continues to receive
subsidy for 90 days from the date the
Child turned 13 years old during the eligibility Child remains eligible through the end of the
period. twelve (12) month eligibility period.
th th
Family moves from 12 St. NE to 5 St. NW. Child remains eligible through the end of the
twelve (12) month eligibility period.
th
Family moves from 12 St. NE to Suitland, Child is no longer eligible. Termination is
MD. immediate.
Parent has a baby. Parent is on parental leave Child remains eligible through the end of the
for 16 weeks. twelve (12) month eligibility period.
Parents adopt a baby. Parent is on parental Child remains eligible through the end of the
leave for 16 weeks. twelve (12) month eligibility period.

500.2 ELIGIBILITY REDETERMINATION: DOCUMENTATION
(a) The eligibility staff will determine what documents are required to verify the
family and child’s eligibility using as their basis the reason for eligibility. The
eligibility staff shall ensure a letter is sent to the parent(s) or guardian(s) that
requests written documentation to update the case file, which may include, but is
not limited to, documentation set forth in Section 300.3. See Appendix 10:
Eligibility Review Appointment.
(b) All documents shall be submitted by the applicant and approved by the eligibility
staff no more than five (5) working days after the date of the redetermination
interview. A request for additional time must be based on extenuating
circumstances and must be approved in writing by the DHS CCSD Program
Manager or Supervisor or by the Director of the Level II child development
facility, and may not exceed fifteen (15) business days. Failure of the parent(s) or
guardian(s) to supply all required eligibility information will result in termination
of the child care subsidy.
500.3 ELIGIBILITY REDETERMINATION: TANF PARENT
If a TANF parent is determined as non-compliant with the work participation

requirements set forth in the TANF parent’s IRP and the TANF parent has failed to
comply the work participation requirements within the timeframe set forth by the DHS
TANF policies, then the child’s continued eligibility must be based on an eligibility
category other than “TANF recipients in countable activities.”
500.4 ELIGIBILITY REDETERMINATION: GRADUATED PHASE OUT
New applicants are eligible for subsidized child care if such applicant(s) can document an
adjusted annual gross family income up to 250 percent of the Federal Poverty Level
(FPL). Families who are classified as being over the income threshold at the end of the
twelve (12) month eligibility period are to be considered eligible up to 300 percent of the
2009 FPL or 85 percent of the current SMI whichever is lower, as provided in Appendix
6: Maximum Income Guidelines for Subsidized Child Care.
Any family already designated as eligible for subsidized child care and receiving such
services whose income reaches 300 percent of FPL or 85 percent of the current SMI
shall continue to receive subsidized care for no more than three (3) months. At the end of
the three (3) month period of continued assistance, if the gross annual family income is
below 300% of FPL or 85% of the most current SMI, assistance cannot be terminated
and the child shall continue receiving assistance until the next scheduled redetermination.
Families who left the program for other reasons may also reapply and be considered if the
gross annual family income is below 300% of FPL or 85% of the most current SMI.
Previous participation must be verified through OSSE DEL MIS.

500.5 ELIGIBILITY REDETERMINATION: APPLICANT’S FAILURE TO RESPOND
It is the eligibility staff’s responsibility to follow through promptly on the steps below to
assure that ineligible children do not remain in the subsidy program.
(a) The eligibility staff shall make every effort to alert the applicant of the need for
redetermination of eligibility. Required steps include:
(1) Adequate prior written notice of appointment to the applicant.
(2) Inclusion of a warning in the letter regarding the consequences for failure
to respond or if the appointment is missed without notice to the worker
(i.e. termination of the subsidy effective the day following the
appointment date).
(3) Forwarding of a copy of the letter to the child care facility.
(4) Attempts by the eligibility staff to contact the applicant by telephone at

home, work or training, and through message at the child care facility to
ensure the applicant is aware that a re-certification is due.
(5) An alert call to the provider if there is no response to attempts to contact

prior to close of business the day of the missed appointment with the
eligibility staff instructing the child care facility to not allow entry of the
child the following day and asking that the parent(s) or guardian(s) be
given a message to call the eligibility staff immediately.
(6) Termination of the child if the parent(s) or guardian(s) fails to contact the
eligibility staff within three (3) days if no response to the request to
contact the worker.
(7) Contact by the eligibility staff with the provider via telephone and a letter
faxed to the provider regarding the immediate termination of the child.
(8) Mailing of a copy of the letter to the provider and the family.
(b) The eligibility staff shall provide written notice and allow the applicant 15
calendar days from the redetermination appointment to secure required documents

if needed before termination is final. The eligibility staff shall explain next steps
shall the parent(s) or guardian(s) fail to comply with the document request.
(c) The eligibility staff shall provide written notice and allow the applicant fifteen
(15) calendar days before termination is final when the parent(s) or guardian(s) is
found ineligible to allow time for an appeal of the eligibility decision. The
eligibility staff shall explain next steps shall the parent(s) or guardian(s) fail to
timely request an appeal of the decision.

SECTION 600
TERMINATION OF SUBSIDIZED CHILD CARE
600.1 REASONS FOR TERMINATION
During a twelve (12) month eligibility period, subsidized child care services shall be
terminated by the eligibility staff as a result on any of the following circumstances:
(a) Eligibility requirements, as set forth in 500.1(b), are no longer met;
(b) The applicant is no longer a resident of the District of Columbia. Termination of

child care shall be immediate, unless a hearing request is filed.
(c) The applicant has failed to complete an eligibility review, including providing the
required supporting documentation, in a timely manner;
(d) An applicant has been found through investigation to have committed child care
fraud. Termination of child care may be immediate, unless a hearing request is
filed; and
(e) A parent, guardian, or child is exhibiting violent, combative, or disruptive

behavior that caused or attempted to cause bodily injury, or threatened serious
bodily injury to another person, unless in self-defense. Termination of child care
may be immediate.
The DHS CCSD or the Level II eligibility staff shall give prior written notice of the
proposed termination from subsidized care for all instances of termination with the
exception of those that require immediate termination. Notice shall be given ninety (90)
calendar days prior to the date of termination. For cases in DHS CCSD, a copy shall be
sent to the provider, as well. The notice shall include the effective date, the reason for the
termination and an explanation of the parent(s) or guardian(s)’ right to appeal the
decision. A copy of this letter shall be kept on file and the termination date shall be
entered into the database. If the applicant complies with all requirements within the
stated time frame, the termination shall be voided prior to the date of termination. If the
case belongs to DHS CCSD, the provider will be sent a void termination notice. See
Appendix 11: Notice of Termination of Child Care Services.
600.2 FRAUD
Fraud is defined as an offense committed by any person who obtains or attempts to

obtain, or aids or abets any person, who pursuant to a scheme to deceive, knowingly
falsifies, conceals or covers up a material fact or makes or uses any false statement,

writing or document to obtain a benefit or payment to which the parent or provider would
otherwise not be entitled. Overpayments are considered intentional if the parent or
provider knowingly withheld or provided false information on matters affecting
eligibility, benefits or a claim for services. A failure to disclose a material fact that
results in obtaining or continuing to receive child care subsidy funds or services for
which the parent or provider is not entitled. Recipient fraud includes the following (this
list is not all inclusive):
(a) With intent to deceive, withholding information regarding eligibility factors such
as gross annual family income, number of family members, ages of family
members, or the recipient’s hours of employment or training;
(b) Knowingly using child care services for an ineligible child; or
(c) Intentionally failing to report any changes which would affect the child’s
eligibility for child care benefits.
All suspected cases of fraud must be referred to OSSE DEL immediately. If OSSE DEL
determines that fraud has occurred, further action may be taken such as collection from
the parent(s) or guardian(s) of funds improperly spent on child care or referral to the
Office of the Attorney General for possible criminal prosecution.
Please forward all cases of suspected fraud to:
The Office of the State Superintendent of Education

Division of Early Learning
Attention: Operations and Grants Management Unit
810 First Street NE, 9th Floor
Washington, DC 20002
You may also report fraud by phone or email to OSSE through email or phone:
Email: OSSE.ChildcareComplaints@dc.gov
Complaint and Unusual Incidents Hotline: (202) 727-2993
Information to include:
Your information will be helpful if you can include the details of who, what, when,
where, and how.
Who is involved? Report as much of the following information you have about the
person, or people, you are calling about. Provide the full name, date of birth, and address
or place of subject. Describe relationships between people involved. Who else knows this
is happening, or is a witness?

What do you believe is the actual fraud, what did the person/people do? Describe exactly
what is happening. What documentation or evidence do you have, or do you know exists?
When did this last occur? Provide date/time. Was this a one-time incident or is it an
ongoing situation? Will this happen again in the future?
Where is the activity taking place? If possible, give details, names of stores, addresses of
residences.
How is this happening? How did you come to find out about it?
An applicant whose fraudulent behavior has been confirmed through investigation may
be permanently barred from receiving child care subsidy services through the DC’s
subsidy program.

SECTION 700
APPEAL/ADMINISTRATIVE HEARING
700.1 AVAILABILITY OF AN APPEAL/ADMINISTRATIVE HEARING
The availability of an appeal process is a requirement of the CCBDG Act to ensure that: the
applicant or recipient’s right to subsidized child care is determined promptly in accordance with
applicable laws and regulations; placements are suitable for the child; and that any co-payment
computation is accurate.
(a) Every applicant or recipient has the right to appeal a decision made by the DHS
CCSD eligibility staff or Level II eligibility staff as a result of any adverse action,
including:
(1) Denial of application;
(2) Termination of services;
(3) Dispute over the amount of the co-payment; or
(4) The applicant’s record of payment.
(b) The DHS CCSD eligibility staff or Level II eligibility staff must inform the
applicant or recipient of:
(1) Their right to appeal any decision;
(2) The process for requesting an Administrative Hearing (previously known

as a Fair Hearing) and the action steps that must be taken if requested;
(3) The requirement for the appeal to be in writing and filed (i.e. received)
within 15 calendar days of the adverse decision;
(4) The availability of the eligibility staff to assist any applicant who conveys
orally the desire to appeal a decision, in writing the appeal if requested.
The applicant must sign the appeal request after review and approval;

(5) The freeze on service provision if the case is in the application stage until
an appeal decision is rendered;
(6) The continuation of existing services with a timely request (within 15

calendar days of notification of the adverse action) until a decision is
rendered;
(7) The possible discontinuation of services when the behavior of the

parent(s) or guardian(s) or child creates a severe disruption to the child
care program or a physical threat to the staff, children, or others. In this
case the provider is not required to have further contact with the family;
(8) The scheduling of a hearing by the Office of Administrative Hearings;
(9) The possibility of the need for additional documentation by the Hearing
Officer;
(10) The expected completion of the process by the Hearing Officer within 60
days after the date of receipt of the original request;
(11) The finality of the decision made by the Administrative Hearing Officer;
and
(12) Receipt of the decision by the Hearing Officer in writing to all parties.
(c) The following steps must be taken by DHS CCSD eligibility staff to ensure an
appropriate response to the Hearing request:
(1) The written appeal shall be submitted directly to the Office of Administrative
Hearings, 441 4th Street, N.W., Suite 450 North, Washington, D.C. 20001.
(2) The Office of Administrative Hearings has responsibility for scheduling the
hearing and notifying the participants, sending a copy of the notice to the
CCSD via the Department of Human Services chain of command and to
OSSE’s Office of the General Counsel.
(3) First Level of Resolution Attempt - The Intake Supervisor or Program

Manager for a DHS CCSD adverse action appeal is expected to offer a face to
face meeting with the applicant in an attempt to mediate the dispute prior to
the date of the Administrative Hearing. If the issue is resolved to the

applicant’s satisfaction, a written, signed statement to that effect must be
obtained from the applicant and forwarded to the Office of Administrative
Hearings, so that the hearing may be cancelled.
(4) Second level of Resolution Attempt - If the issue is unresolved, an

Administrative Review at the departmental level in the Department of Human
Services is expected to be offered to the applicant as part of the ongoing
attempt to resolve the issue. If the applicant does not attend the Review or
the issue is still not resolved, the Administrative Hearing will continue as
originally scheduled.
(5) Third level of Resolution Attempt – When administrative review fails to

resolve the issues, the Administrative Hearing is expected to proceed. The
DHS CCSD eligibility staff responsible for the disputed decision is expected
to participate along with supervisory staff in the hearing.
(d) The following steps must be taken by Level II eligibility staff to ensure an
appropriate response to the Hearing request:
(1) The written appeal shall be submitted directly to the Office of

Administrative Hearings, 441 4th Street, N.W., Suite 450 North,
Washington, D.C. 20001.
(2) The Office of Administrative Hearings has responsibility for scheduling

the hearing and notifying the participants, sending a copy of the notice to
OSSE’s Office of the General Counsel.
(3) First Level of Resolution Attempt - OSSE DEL Director of Operations

and Management is expected to offer a face to face meeting with the
applicant in an attempt to mediate the dispute prior to the date of the
Administrative Hearing. If the issue is resolved to the applicant’s
satisfaction, a written, signed statement to that effect must be obtained
from the applicant and forwarded to the Office of Administrative
Hearings, so that the hearing may be cancelled.
(4) Second level of Resolution Attempt - If the issue is unresolved, an

Administrative Review at the departmental level in OSSE DEL is
expected to be offered to the applicant as part of the ongoing attempt to
resolve the issue. If the applicant does not attend the Review or the issue
is still not resolved, the Administrative Hearing will continue as originally
scheduled.

(5) Third level of Resolution Attempt – When administrative review fails to
resolve the issues, the Administrative Hearing is expected to proceed. The
Level II eligibility staff responsible for the disputed decision is expected
to participate along with OSSE DEL supervisory staff in the hearing.
(e) The applicant has the following rights during the hearing process:
(1) To be represented by legal counsel or by a lay person who is not an

employee of the DC; and
(2) To bring witnesses on their behalf.

SECTION 800
PAYMENT TO PROVIDERS
800.1 PAYMENT
The child care providers in the subsidy program receive a payment from the DC once per
month and a co-payment, when assessed, from the parent(s) or guardian(s). The rate paid
by the DC shall not exceed the daily rate paid by non-subsidized (private) children at that
facility. Child care providers are paid a daily rate based upon the child’s age and the
service being provided under the various full-time and part-time categories, traditional or
non-traditional hours and according to the provider’s tier level. Payment is made for
each child enrolled and for each day a child remains enrolled. The payment is made after
receipt and verification of monthly traditional attendance is submitted to the OSSE
Attendance Tracking System (OATS) or non-traditional attendance is submitted via the
paper attendance forms and is due each month. This form is used to identify each child’s
daily participation in child care and is due each month by the fifth (5th) business day for
services rendered the previous month. All supporting documentation shall be included
with the attendance form submission. Payment can be expected by the end of each month
when the attendance report is submitted timely.
DC makes payment pursuant to the execution of a Provider Agreement with each

provider which includes identification of the types of services provided by that provider.
Checks are processed by the Office of the Chief Financial Officer (OCFO). Providers are
expected to review and reconcile monthly the pay statement against the attendance form
submitted to the OSSE to ensure the accuracy of each payment.
Level I providers shall receive a subsidy payment that is the difference between OSSE
DEL daily contract cost of care and the assigned co-payment.
Level II providers shall receive the full OSSE DEL daily contract rate to compensate the
provider for the additional responsibility, time and costs incurred related to determining
eligibility.
DC is not responsible to recover any monies that are owed to a Provider by the parent(s)
or guardian(s).
800.2 PAYROLL PROCESSING
The payroll is drawn from the OSSE DEL MIS (database), in which children are assigned
to specific providers. DHS CCSD Eligibility staff are responsible for assignment in the
computer of each child whose placement has been authorized by DHS CCSD, once the
completed admission slip has returned. The Level II eligibility staff must enter the family
information into the database and assign the child when intake is done by the provider.
All data entry affecting assignments shall be entered correctly and as quickly as possible
after placements or changes occur.

Once an assignment is “accepted” in the database, most changes in the payroll occur
without further intervention by the eligibility staff. The child care subsidy System is
programmed with the number of days to be paid for each month and with the rates for
each type of service. Prior to running each month’s payroll, OSSE eligibility staff
activates changes in the categories as needed to reflect the current age of each child (for
example, from preschool to school age based on date of birth. When a termination date is
entered into the database, the system will end the payment. Note: payment is made
through and including the date entered for termination.
(a) The Child Care Payment Adjustment Authorization form needs to be filled out by
the DHS CCSD worker or OSSE Eligibility Monitor only in the following limited
situations:
(1) When an initial payment, change or termination is authorized late

(effective prior to the current payroll period);
(2) When a change has been made in an assignment that requires explanation;
for example, when the effective date of a change or termination date does
not match the date in the computer; or
(3) To authorize non-traditional services.
800.3 PAYMENT ERRORS
Providers must review and reconcile monthly the pay statement against the attendance
report submitted to OSSE to ensure the accuracy of each payment.
Discrepancies, whether in the form of an overpayment or underpayment, are to be

reported to the attention of OSSE DEL by the provider. The “Payment Summary Error
Report” must be completed to identify any errors. See Appendix 12: Payment Summary
Error Report Form. OSSE reserves the right to deny payment for any discrepancies
reported that are more than three (3) months old as well as any discrepancy that fails to
meet the requirements for appropriate supporting documentation to verify the request.
An investigation will take place to confirm the need for a payment adjustment and the
Payment Adjustment Form must be completed and approved by OSSE DEL Child Care
Eligibility Monitor or a designee before being forwarded to the Accounts Payable Unit.
OSSE must review each Payment Adjustment form received and must check past payroll
as appropriate to determine whether the overpayments or underpayments authorized are
justified. OSSE staff shall compute the adjustment needed and enter any changes into the
payroll program to be incorporated into the current payroll.

Children experiencing homelessness are provided a sixty (60) calendar day grace period
in which to provide full documentation of eligibility. Provided the eligibility staff has
established the child is experiencing homelessness and the eligibility workers has
completed OSSE’s Child Care Referral Form, child shall receive, and the provider shall
be paid for, subsidized child care during the grace period. If, after full documentation is
provided, the child experiencing homelessness is found to be ineligible, subsidized child
care services shall be terminated pursuant to Section 700. Additionally, OSSE shall pay
any amount owed to a child care provider for services provided as a result of the initial
eligibility determination and payment made prior to the final eligibility determination
shall not be considered an error or improper payment.
800.4 OVERPAYMENTS
report submitted to OSSE to ensure the accuracy of each payment.
Overpayments are to be recovered regardless of the amount. Recovery may be achieved

through deduction(s) from future checks in a plan agreed upon by OSSE based on the
OSSE’s Child Care Payment Recoupment Policy effective October 1, 2015.
800.5 UNDERPAYMENTS
report submitted to OSSE to ensure the accuracy of each payment. Discrepancies must
be reported immediately to OSSE DEL using the Payment Summary Error Report form
(Appendix 12).
Correction for underpayments shall be made in full by OSSE on the pay cycle following
confirmation by OSSE DEL that monies are owed and computation confirmation of the
amount to be paid by OSSE DEL staff. OSSE reserves the right to deny payment for any
discrepancies reported that are more than three (3) months old or cross into another fiscal
year budget, as well as any discrepancy that fails to meet the requirements for appropriate
supporting documentation to verify the request.
It is the responsibility of all providers to carefully review their monthly pay statement
and immediately report any discrepancies by way of the Payment Summary Error Report
form (Appendix 12).
800.6 RESPONSIBILITIES FOR ATTENDANCE REPORTING AND PAYMENT

(a) Providers are reminded that compliance with all OSSE child care subsidy
program policies and procedures is mandatory for continued participation as a
provider in the program. Failure to perform any of the following is a violation of
the requirements of the Child Care Subsidy Provider Agreement:

(1) Failure to return the signed admission form to the DHS CCSD within
thirty (30) days of the date that the child starts in the program;
(2) Failure to submit timely and accurate attendance reports;
(3) Failure to review and reconcile the attendance report with the payment
received; or
(4) Failure to report payment errors timely (within one (1) month) whether
overpayment or underpayment using the Summary Error Report form with
appropriate supporting documents to OSSE DEL.
(b) OSSE DEL shall take appropriate corrective action when a provider has more
than two (2) violations of these requirements during any given agreement period.
Corrective action may include mandatory re-training on provider reporting
requirements, issuing a ‘stop placement’ order until the provider has demonstrated
an understanding and compliance with attendance reporting requirements for at
least three (3) consecutive months, or possible termination of the agreement.
800.7 HOLIDAYS
Payment shall be based upon the enrollment of eligible children in attendance during a
given month. Licensed child care centers and licensed family child care home providers
are paid for the following Holidays:
(a) New Year’s Day;
(b) Birthday of Martin Luther King, Jr.;
(c) Presidents Day;
(d) District of Columbia’s Emancipation Day;
(e) Memorial Day;
(f) Independence Day;
(g) Labor Day;
(h) Columbus Day;
(i) Veterans Day;
(j) Thanksgiving Day;
(k) Christmas Day; and

(l) January 20th during years there is a Presidential Inauguration.
800.8 STAFF DEVELOPMENT
DC allows a licensed child care center and a licensed family child care provider to be
closed for five (5) days during each provider agreement year with full payment for staff
development. Providers must give a thirty (30) day notice to and receive written
approval from OSSE DEL for all non-government closings, including staff development.
Twenty-one (21) clock hours of staff development is required for bronze tier level
providers annually; twenty-seven (27) clock hours for silver tier level providers annually
and thirty-three (33) clock hours for gold tier level providers annually.
800.9 SNOW AND INCLEMENT WEATHER DAYS
DC permits child care facilities to close whenever the District of Columbia Public
Schools (DCPS) close due to inclement weather.
800.10 ATTENDANCE
(a) Payment is made for each child enrolled under DHS CCSD or Level II provider
authorization and for each day a child remains enrolled.
(b) Payment will be authorized for the provider for any of the following absences:
(1) Five (5) days of unexcused absence per month before the payment is
stopped for the balance of the month;
(2) Fifteen (15) days of excused absences in a month may be approved.

Excused absences may include childhood diseases or injury, or family
emergencies. Documentation of these situations must be provided to the
child care provider and the provider must submit this documentation with
their monthly attendance report as well as noting the reason on the
attendance; or
(3) Fifteen (15) days of vacation annually during the period of eligibility.
(c) The parent(s) or guardian(s) is expected to notify the licensed child care facility in
writing of plans to be absent.
(d) Payment termination is justified after five (5) days of unexcused absence and 15
days of excused absence.

SECTION 900
GLOSSARY OF KEY TERMS
This glossary contains definitions of key terms, concepts and acronyms used in this manual:
Applicant The parent(s) or guardian(s) who makes initial application for

subsidized child care.
CFSA Child and Family Services Agency.
Child An individual who is less than thirteen (13) years of age; or under
nineteen (19) years of age with special needs.
Child Care Care provided to an eligible child by an eligible child care

provider.
Child Experiencing A child who lacks a fixed, regular, and adequate nighttime
Homelessness residence and includes children and youths:
(a) Sharing the housing of other persons due to loss of housing,

economic hardship, or a similar reason;
(b) Living in motels, hotels, trailer parks, or camping grounds
due to the lack of alternative adequate accommodations;
(c) Living in emergency or transitional shelters (including DC
transitional housing); are abandoned in hospitals; or are
awaiting foster care placement;
(d) In 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;
(e) Living in cars, parks, public spaces, abandoned buildings,
substandard housing, bus or train stations, or similar settings;
(f) Migratory children, as defined in section 1309 of the
Elementary and Secondary Education Act of 1965 (20 USCS
§ 6399), who qualify as homeless because they live in
circumstances described above; and
(g) Unaccompanied youth, including youths who are not in
physical custody of a parent or guardian, who qualify as
homeless because they live in circumstances described
above.
Co-payment An amount determined to be the parent(s) or guardian(s) share of

the daily cost of care and to be paid by the parent(s) or guardian(s)

to the child care provider. Also referred to as the parent fee.
DHS Department of Human Services.
DHS CCSD Department of Human Services Child Care Services Division.
DOES Department of Employment Services.
Eligibility Staff The DHS CCSD staff or the Level II child care center staff person
responsible for determining the child’s eligibility for subsidized
child care.
ESA Economic Security Administration.
Family A unit consisting of one or more adults and children related by

blood, marriage, adoption or legal guardianship who reside in the
same household.
Fraud An offense committed by any person who obtains or attempts to

obtain, or aids or abets any person, who pursuant to a scheme to
deceive, knowingly falsifies, conceals or covers up a material fact
or makes or uses any false statement, writing or document to
obtain a benefit or payment to which the parent or provider would
otherwise not be entitled. Overpayments are considered
intentional if the parent or provider knowingly withheld or
provided false information on matters affecting eligibility, benefits
or a claim for services. A failure to disclose a material fact that
results in obtaining or continuing to receive child care subsidy
funds or services for which the parent or provider is not entitled.
Recipient fraud includes, but is not limited to, the following: with
the intent to deceive, withholding information regarding eligibility
factors such as gross annual family income, number of family
members, ages of family members, or the recipient’s hours of
employment or training; knowingly using child care services for an
ineligible child; or failing to report any changes which would
affect the child’s eligibility for child care benefits (purposeful
deception).
Gross Annual Family The combined gross countable income of all family members
Income living in the same household who are included for purposes of
determining family size. Used to determine income eligibility and
co-payments.
IEP Individualized Education Plan.
IFSP Individualized Family Service Plan.

Income Eligibility A method for determining eligibility which is based on
establishing that the applicant’s gross family income is no more
than the maximum income level allowable based on family size.
Infant and Toddler A child birth to thirty-six (36) months of age.
Level II Providers Child care center providers authorized to conduct initial eligibility
determinations and redeterminations for families seeking child
care subsidy under specified eligibility categories.
MIS Management Information System.
Non-Temporary Change Any cessation of work or attendance at a training or education

program that exceeds 90 calendar days.
OSSE Office of the State Superintendent of Education.
OSSE DEL Office of the State Superintendent of Education, Division of Early

Learning. Formerly the Office of Early Childhood Education
(ECE).
Overpayment The amount of money received over the correct payment to which
the payee was not entitled.
Preschooler For payment purposes, a child thirty-six (36) months of age or

older, but less than five (5) years of age on or before September
30th of that year.
Provider A licensed child development center, a licensed family child care

home or expanded home, or a person approved as an in-home or
relative caregiver.
Qualifying Activity A qualifying activity shall include:
(a) Employment (including through an agency or self-

employed);
(b) Job Search;
(c) Training Program;
(d) Work Experience Program;
(e) Job Corps;
(f) Teen or young adult parent in high school or G.E.D.
Program
(g) Student in Undergraduate Program; or
(h) Summer School Program (including undergraduate program).

Recipient An individual child who is determined eligible for and receives
subsidized child care.
Resident Or Residence In absence of the contrary, residence of a child shall be presumed

to be the residency of the child’s parent(s) or guardian(s). The
residence of a parent(s) or guardian(s) is where the person(s) has
established a physical presence, the actual occupation and
inhabitance of a place of abode with the intent to dwell for a
continuous period of time.
School-Age Child A child five (5) years of age on or before September 30th of that
year through the age of twelve (12) or under the age of nineteen
(19) if the child has a disability.
Special Needs Conditions or characteristics of a child under the age of 19 that

reflect a need for particular care, services or treatment, most
commonly physical and/or mental disabilities and/or delays and is
evidence by IFSP or IEP.
Subsidized Child Care Child care provided in a licensed child development facility, a
relative child care home, or in a child’s home for fewer than 24
consecutive hours a day for which the government provides
reimbursement to the provider.
TANF Temporary Assistance to Needy Families, as defined in the District

of Columbia Public Assistance Act of 1982, as amended, effective
April 6, 1982 (D.C. Law 4-101; D.C. Official Code Section 4-
201.1 et seq.).
TANF Payee A guardian(s) or custodian(s) who is providing care to child who is

not their natural child and receiving financial assistance though
ESA on behalf of the child.
TANF Vendor An organization contracted with ESA to provide job training and
job placement for TANF recipients.
Teen or Young Adult A parent under the age of 26 years old.

Parent
Temporary Change A temporary change shall include any of the following:
(a) Any time limited absence from work for employed parent or
guardian due to reasons such as need to care for a family
member or an illness;
(b) Any interruption in work for a seasonal worker who is not
working between regular industry work seasons;

(c) Any student holiday or break for a parent or guardian
participating in training or education ;
(d) Any reduction in work, training or education hours to less
than twenty hours per week, as long as the parent or guardian
is still working or attending training or education;
(e) Any other cessation of work or attendance at a training or
education program that does not exceed ninety (90) calendar
days;
(f) Any change in age, including turning thirteen (13) years old
during the eligibility period; and
(g) Any change in residency within the District of Columbia.
Underpayment A payment received by a provider which is less than the allowable

amount owed for service provided in accordance with a particular
child care agreement.
Vulnerable Child For the purposes of eligibility:
(a) A child with special needs;

(b) A child experiencing homelessness;
(c) A child in foster care;
(d) A child of an adult with disabilities; or
(e) A child of recipients of vocational rehabilitation services.

APPENDIX 1
SUBSIDIZED CHILD CARE CASE RECORD REQUIREMENTS
Requirements:
• The Eligibility Worker must initial each item obtained for the file.
• Every file (except for Foster Parent and Children under Protective Services) must contain a completed
Application for Subsidized Child Care signed by the applicant and Eligibility Worker. The file must have
supporting documentation for eligibility and calculations of the family income for determination of the
family’s co-payment. Copies of any payment adjustment forms shall be included in the record.
• The eligibility records for any staff member employed by a Level II provider shall be securely maintained
in the DHS/CCSD office. The folder should be labeled with the applicant’s (adult’s) name and should
contain individual eligibility information for all children in the family.
• Documents must be organized chronologically in the family case record with the most recent dated
documents on top. Notes must be kept to document work with each case. At a minimum a 2- part folder
must be used.
• Level II Eligibility Workers shall maintain an eligibility folder for each family referred with an admission
from DHS/CCSD. It must contain the admission form and any subsequent correspondence from the DHS/
CCSD Eligibility Worker regarding the family.
• The child’s file at a child development facility, which includes the child’s health record shall be
maintained separately from the eligibility record at the child care facility in accordance with 5A DCMR
Chapter 1. The child’s enrollment record and the child’s health record shall not include any forms related
to the child’s eligibility for subsidized care.
• The DHS CCSD eligibility staff shall keep a copy of each admission form when issued, until such time as
the signed copy is returned. A “voided” copy with written explanation shall be maintained if the
admission form is not returned as a result of non- attendance.
• Level II child development centers must return closed case records within three (3) months of termination
to DHS CCSD. Closed case records must be maintained on site at DHS CCSD for a minimum of five (5)
years.
Organize the folder as follows:
Left Side Right Side
Application for Subsidized Child Care Services Termination letter (copy)
Child care referrals Check List
Child care admission forms Record of case action form
Health Certificates (for DHS/CCSD records, Level Case status documentation (letter or referral from
II must maintain separately) CFSA, DC Superior Court, Vocational
Rehabilitation, etc., confirming ongoing status)
Adoption papers, custody orders Proof of disability
Birth Certificates Preview letter (copy)
Picture IDs Proof of Employment or training
Proof of child care deduction
Proof of dependents college education
Work/school schedule
ESA/DCAS printout or letter from ESA
Proof of residence
Child care payment adjustment authorization form
(grouped by child with most recent on top)
810 First St. NE, Ninth Floor, Washington, DC 20002 • Phone: (202) 727-6436 TTY: 711 • osse.dc.gov
APPENDIX 2
RECORD OF CASE ACTION
CASE NAME (Parent): ____________________________________
DATE ACTIONS TAKEN Initials
810 First St. NE, Ninth Floor, Washington, DC 20002 • Phone: (202) 727-6436 TTY: 711 • osse.dc.gov
APPENDIX 3
APPLICATION FOR SUBSIDIZED CHILD CARE SERVICES
Names, Addresses, and income information of both parents must be reported.
Please complete all blanks, including information of absent parent, and attached required documents (PLEASE PRINT)
PARENT(S) AND/OR GUARDIAN INFORMATION
1. Name of Applicant: ____________________________________________________ DOB: _____________ SSN:__________________________

(Parent, Guardian or Payee) Last First MI (optional)
Race (optional) [ ] American Indian or Alaskan Native [ ] Asian [ ] Black or African American [ ] White [ ] Native Hawaiian or Other Pacific Islander
Ethnicity (optional) [ ]Not Hispanic/Latino [ ] Hispanic/Latino
Address:__________________________________________________________________________________________________________ _______
Street Apartment City State Zip Code Ward
Telephone No: _________________________________________ ___________________________________________________

Home with Area Code Work/School with Area Code
2. LANGUAGE PREFERENCE: What is the Primary Language you speak?
Please select one
[ ] English [ ] Mandarin Chinese [ ] Cantonese Chinese [ ] Vietnamese [ ] Amharic [ ] French [ ] Spanish [ ] Other________________________________
3. MARITAL STATUS:______________________________
4. MILITARY SERVICE: [ ] Active Duty U.S. Military [ ] National Guard or Military Reserve [ ] None
5. DESCRIBE YOUR CURRENT HOUSING STATUS: [ ] I live in an adequate and permanent house [ ] I live in a homeless shelter [ ] I live in a hotel or motel
because I have no alternative accommodation [ ] I share housing with others because I have no alternative accommodation [ ] I do not have any housing
6. Name of Spouse/Other Parent: ____________________________________________________ DOB: _____________ SSN:__________________________

Last First MI (optional)
Race (optional) [ ] American Indian or Alaskan Native [ ] Asian [ ] Black or African American [ ] White [ ] Native Hawaiian or Other Pacific Islander
Ethnicity (optional) [ ]Not Hispanic/Latino [ ] Hispanic/Latino
Address:____________________________________________________________________________________________________________ ________
Street Apartment City State Zip Code Ward
Telephone No: _________________________________________ _____________________________________________________

Home with Area Code Work/School with Area Code
CHILD INFORMATION ( LIST ALL CHILDREN IN THE FAMILY)

Complete this section for each child in the family. Use the code below to complete the Citizenship, Race, Ethnicity and Language columns. Enter each
code that applies, using at least one code for each child. Enter “Yes” or No’ in the Special Needs column to indicate if the child has a special need.
Citizenship/Immigration Code: 1= United States Citizenship, 2= Permanent Resident, 3= Granted conditional entry, 5=Parolee 1 year or more,
6= Deportation withheld, 7= Refugee, 8= Battered spouse, child, or parent of child(ren)
Ethnicity Codes: 1 =Yes/Hispanic or Latino, 2= No/Hispanic/ Latino
Race Code: 1= American Indian/ Alaskan Native, 2= Asian, 3= Black/ African American, 4= White, 5= Native Hawaiian/Pacific Islander
Language: 1= English, 2= Mandarin Chinese , 3=Cantonese Chinese , 4=Vietnamese, 5= Amharic , 6= French , 7= Spanish , 8=Other______________________
.
Name DOB SSN Sex Special Citizen- Eth- Race Language Child ‘s Father or Mother
(optional) Needs ship/ nicity ( If this person different
Immi-
Last First from # 6)
Gration
Status Name / DOB/ SSN
(optional)
PARENT(S) AND /OR GUARDIAN ACTIVITY INFORMATION
Your Activity Spouse/ Other Parent Activity
1. Name of school or employer:________________________________ 1. Name of school or employer:________________________________
Address:___________________________________________________ Address:___________________________________________________
Days and hours of your activity:_________________________________ Days and hours of your activity:_________________________________
Start and end dates of activity:_________________________________ Start and end dates of activity:_________________________________
2. Name of school or employer:________________________________ 2. Name of school or employer:________________________________
Address:___________________________________________________ Address:___________________________________________________
Days and hours of your activity:_________________________________ Days and hours of your activity:_________________________________
Start and end dates of activity:_________________________________ Start and end dates of activity:_________________________________
REASON FOR CHILD CARE

.
WORKING TRAINING CHILD WITH A SPECIAL NEED OTHER ______________________________________________
HOUSEHOLD INCOME INFORMATION:
Gross Amount
Type of income per
How often: (check one)
pay period
Mother’s/Guardian’s Income ⁪ weekly ⁪ bi-weekly ⁪ bi-monthly ⁪ monthly
Father’s/ Guardian’s Income ⁪ weekly ⁪ bi-weekly ⁪ bi-monthly ⁪ monthly
Child Support ⁪ weekly ⁪ bi-weekly ⁪ bi-monthly ⁪ monthly
Alimony ⁪ weekly ⁪ bi-weekly ⁪ bi-monthly ⁪ monthly
SSI Benefits ⁪ weekly ⁪ bi-weekly ⁪ bi-monthly ⁪ monthly
Unemployment Benefits ⁪ weekly ⁪ bi-weekly ⁪ bi-monthly ⁪ monthly

Other:_______________________ ⁪ weekly ⁪ bi-weekly ⁪ bi-monthly ⁪ monthly
TANF ⁪ Yes $___________________ ⁪ No
Food Stamp ⁪ Yes $___________________ ⁪ No
Social Security ⁪ Yes $___________________ ⁪ No

Attach proof of all income for: applicant, spouse, parents of minor parent,
adult and spouse with physical custody of minor child.
CHILD SUPPORT INFORMATION
1) Are you receiving child support for all children in your household who are eligible for child support? ⁪ Yes ⁪ No
2) Have you applied for child support for all children in your household eligible to receive child support? ⁪ Yes ⁪ No
DISTRIBUTION – Original in Case Folder
2
RIGHTS AND RESPONSIBILITIES OF APPLICANT
FOR SUBSIDIZED CHILD CARE SERVICES
RIGHTS:
I understand that if I am not satisfied with any decision by the Department regarding eligibility, my receipt or termination of
services, I may request a Fair Hearing. If I am receiving services and request a Fair Hearing before the effective date of this
action, my benefits will continue uninterrupted until a hearing decision is made. If I do not request a Fair Hearing before the
effective date of this action, I may request a hearing within 90 days from the date of the notice of the action, but I will not
continue to receive benefits while the hearing is pending. I must make my request by phone or in writing to:
The Office of Administrative Hearings,
441 4th Street, N.W., Suite 450 North
Washington, D.C. 20001
Phone: (202) 442-9094/Fax: (202) 442-4789
or I can ask my caseworker to help me make the request. After requesting a Fair Hearing the Department will send me a
written notice telling me the time and place of the Administrative Review. The Administrative Review is not the same as a
Fair Hearing. This means I may meet with Department staff to try to resolve my issue. If I choose not to attend the review,
or if my issue is not resolved at the review, this in no way impacts my Fair Hearing with the Office of Administrative
Hearings. If the review resolves my issue, I alone may decide to withdraw my request for a Fair Hearing.
If I request a fair hearing, I understand that (1) I have the right to be represented by legal counsel or by a lay person who is
not an employee of the District; (2) I may bring witnesses on my behalf; (3) reasonable expenses related to the hearing, such
as transportation costs for me or my witnesses, will be paid by the Mayor; and (4) legal services are available to me.
I have been informed that I may choose one of the following types of child care: child care in a child development center,
child care in a family child care home, child care in my home by an adult or relative I identify, or child care in the home of
my relative. I am aware that to choose child care in my home with an adult other than a relative I must first attempt to locate
child care at a minimum of 3 child care centers and/or family child care homes.
I understand that I will be notified in writing within a minimum of 15 days of the effective date of any adverse action by the
Agency such as intention to discontinue, withhold, terminate, suspend, reduce assistance or make assistance subject to
additional conditions. I understand that I may apply for a Fair Hearing as described above if I disagree with notice of any
adverse action.
RESPONSIBILITIES:
____I understand that I must fully and accurately report circumstances affecting my eligibility, relating to family
relationships, employment or training status, income, place of residence, and telephone numbers, and must provide original
documentation to substantiate the information. I must report any changes in these circumstances within 10 calendar days. I
must cooperate with all agency efforts to verify the eligibility information.
____I have been informed of the absence policy and that I must provide documentation of excused absences to the child care
provider. If my child is absent 6 days or more in one month without an adequate excuse I am aware that he/she may be
terminated from the provider site. I have also been informed that I must report within 3 days when my child no longer
attends a facility. I have been informed that I am required to have an eligibility review completed on ___________ (date)
and every _______ months thereafter, to determine if I am eligible to continue receiving subsidized child care. I understand
that a notice will be sent to the address I have provided informing me of the appointment date and time and if I do not appear
for the appointment or reschedule the appointment my child care benefits will be terminated. As noted in paragraph one, I
have the right to a fair hearing.
____I understand that I am responsible for making all co-payments directly to the child care provider for the entire time the
child is enrolled even on days the child is absent. Failure to be up to date with co-payment may result in termination of
services.
WARNING TO APPLICANTS:
Government officials will rely on the information you provide on this application to determine your eligibility for Subsidized
Child Care Services. You are therefore informed that it is a criminal offense under District of Columbia law for you to
knowingly make false or misleading statements on this application. Persons convicted of making false or misleading
statements shall be fined up to $1,000 or imprisoned for up to 180 days or both. By signing your name below you are
3
certifying that you are aware of the penalties for making false or misleading statements on this application. Accordingly, if
you are not sure of the accuracy of the information requested, it is your responsibility to bring the information to the attention
of the appropriate government employee prior to signing the application. See D.C. Code § 22-2514
INFORMATION ON SOCIAL SECURITY NUMBER:

In accordance with ACYF-PI-CC-00-04. U.S. Department of Health and Human Services, Administration on Children, Youth
and Families. Issuance Date: October 27, 2000, the social security number is not required for determining eligibility for
subsidized child care. Eligibility will not be denied should an applicant not provide a Social Security Number. Social
Security Numbers will be used solely for searching for records in a database and for identifying individuals with the same
name. All applicant files are kept confidential.
I have read and agree to the following:

• I have read and understand my rights and responsibilities, and have attached/will provide the required
documents. I certify that this is a true and accurate statement of the financial status and composition of my
household.
• I authorized the Subsidized Child Care Program to obtain any verification necessary to both determine and review
financial eligibility and child care needs. This authorization includes the release of information regarding my
employment, salary, work schedule, and /or training/ school schedule and residence.
• I certify that the family assets do not exceed $1,000,000.
APPLICANT SIGNATURE: ____________________________________________ DATE: __________________

Print Name
______________________________________________________
Signature
AGENCY USE ONLY
Annual Gross Income: _____________________
Family Size: _________________________ Dependent Children: ________________
View DCAS/ TANF verification: ______________________ (Yes /No)
Total Parent Copayment: $_________________ (daily) $__________________ (weekly, if applicable)
Child 1________________________________Parent Fee: $_______________ Other Fee: $_______________
Child 2________________________________Parent Fee: $_______________ Other Fee: $_______________
INITIAL ELIGIBILITY DETERMINATION ELIGIBLE

INELIGIBLE______________________________________________
Specify reason if ineligible
I hereby certify that the rights and responsibility have been discussed with the applicant and she/he has signed
to verify her/his understanding:
ELIGIBILITY WORKER:______________________________________________________DATE:__________________________
Print Name
______________________________________________________
Signature
4
APPENDIX 4
NONTRADITIONAL CHILD CARE ADMISSION FORM
TO BE COMPLETED BY THE ELIGIBILITY WORKER
This is to authorize NON-TRADITIONAL child care admission for:
Child’s Name: ___________________________________________________ SSN: __________________

(optional)
Parent/Guardian : _______________________________________________ SSN: _________________
(optional)
Beginning Date: _______________ Child Care Provider:__________________________________________
Child Placement: Category: CDC CDH CDX RHC IHC
OSSE Payment:_______/______ Parent Co-Payment: ______/______ OSSE Daily Payment Rate: _______/______
Type of Service: ___________________________________________ Full Time [ ] Part Time [ ]

[ ] Infant [ ] Toddler [ ] Pre-school [ ] School Age
Type of Service: ___________________________________________ Full Time [ ] Part Time [ ]

[ ] Infant [ ] Toddler [ ] Pre-school [ ] School Age
COMMENTS: _________________________________________________________________________________________
______________________________________________________________________________________________________
Eligibility Worker:________________________________ Contact No.______________________________
Eligibility Worker’s Signature: ___________________________________ Date: _________________
***** NO PAYMENT WILL BE MADE UNLESS THIS PROCEDURE IS FOLLOWED *****
The Child Care Admission form is only valid for the child care provider listed above and must be signed and returned to the Child Care
Services Division (CCSD) the day the child begins child care.
The Child Care Admission Form becomes INVALID if the child is not enrolled in the facility named above within thirty (30)
calendar days of the date authorized to begin child care.
No changes should be made to the above section completed by CCSD Eligibility Worker by the parent, provider or anyone else;
otherwise this authorization for child care will become INVALID.
Customer Signature: _____________________________________________ Date: _________________
TO B E C O M P L E T E D B Y C H I L D C A R E P R O V I D E R
Date Child Admitted: _____________________________
NAME OF PERSON AUTHORIZED TO SIGN:
Print name: ______________________________________________ Phone Number: _________________________
Signature:_________________________________________________________ Date: __________________________
PLEASE E-MAIL OR BRING THE COMPLETED FORM (SIGNED AND DATED) WITH TRANSMITTAL TO:
Economic Security Administration
Child Care Services Division (CCSD)
4049 South Capitol Street, SW
Phone: (202) 727-0284 Fax: (202) 727-9709
APPENDIX 4
TRADITIONAL CHILD CARE ADMISSION FORM
TO BE COMPLETED BY THE ELIGIBILITY WORKER
This is to authorize TRADITIONAL child care admission for:
Child’s Name: ___________________________________________________ SSN: __________________

(optional)
Parent/Guardian Full Name: ______________________________________ SSN: _________________
(optional)
Beginning Date: _______________ Child Care Provider and Site:_________________________________________
OSSE Payment:______/____ Parent Co-Payment: _____/____ OSSE Daily Payment Rate: ______/_____
CHILD PLACEMENT: Category: CDC CDH CDX RHC IHC

Age Group: Infant Preschool Toddler School Age
Description: FT PT B/A QIN PRE-KEEP
Provider Type: Level I Level II
Eligibility Worker:________________________________ Contact No.______________________________
Eligibility Worker’s Signature: ___________________________________ Date: _________________
***** NO PAYMENT WILL BE MADE UNLESS THIS PROCEDURE IS FOLLOWED *****
The Child Care Admission form is only valid for the child care provider listed above and must be signed and returned to the Child Care
Services Division (CCSD) the day the child begins child care.
The Child Care Admission Form becomes INVALID if the child is not enrolled in the facility named above within thirty (30) calendar
days of the date authorized to begin child care.
No changes should be made to the above section completed by CCSD Eligibility Worker by the parent, provider or anyone else; otherwise
this authorization for child care will become INVALID.
Customer Signature: _____________________________________________ Date: _________________
TO B E C O M P L E T E D B Y C H I L D C A R E P R O V I D E R
Date Child Admitted: _____________________________
NAME OF PERSON AUTHORIZED TO SIGN:
Print name: ______________________________________________ Phone Number: _______________________
Signature:_________________________________________________________ Date: _________________________
PLEASE E-MAIL OR BRING THE COMPLETED FORM (SIGNED AND DATED) WITH TRANSMITTAL TO:
Economic Security Administration

Child Care Services Division (CCSD)
4049 South Capitol Street, SW
Phone: (202) 727-0284 Fax: (202) 727-9709
APPENDIX 5
CHILD CARE REFERRAL
REFERRING AGENCY: ESA __ DCPS ___ Other (Specify) _____________________________
ESA TANF VENDOR _____________________________________________________________________

Name Address
Customer’s Name:__________________________________ Date of Birth:___________ SSN:__________________

(optional)
_______________________________________ Washington D.C. _________ Home Phone: __________________
Address Zip Code
Customer Activity Employed [ ] _______________________ Training [ ] _________________________

Name of Work Site Name of training site
Job Search [ ] _______________________ Start Date: ____________________
______________________________________________________ _____________________________________
Employer/Training Site Address Telephone No. Employer/Training Site
Days per week in training _______ Work____________ Hours Daily _________________ to ________________
_____________________________________________ _____________________________________________
(Print) Referring Worker’s Name Telephone No. Signature of Referring Worker Date
List all Child (ren) in Family:
CHILD’S FULL NAME SSN DOB SEX NEEDS CHILD CARE?

(optional)
_____________________________ ____________________ ________ ____ _______________________
_____________________________ ____________________ ________ ____ _______________________
_____________________________ ____________________ ________ ____ _______________________
_____________________________ ___________________ ________ ____ _______________________
_____________________________ ___________________ ________ ____ _______________________
FOR AGENCY USE ONLY
Date Received: Logged by: _________________________ Date:___________________
ACTION TAKEN
[ ] Child (ren) placed in child care. [ ] Unable to arrange child care
[ ] Customer failed to respond to appointments for child care [ ] Child care terminated
____________________________________________ ______________________________________________
Name of Eligibility Worker (Print) Signature of Eligibility Worker Date
File in case record

APPENDIX 6
MAXIMUM INCOME GUIDELINES FOR SUBSIDIZED CHILD CARE
NEW INTAKE
250% FY 2009 Federal Poverty Level or 85% District Median Income
Family Size Maximum Gross Annual

Income
1 $ 27, 075
2 $ 36,425
3 $ 45,775
4 $ 55,125
5 $ 64,475
6 $ 73,825
7 $ 82,127
8 $ 83,952
9 $ 85,777
10 $ 87,602
MAXIMUM INCOME GUIDELINES FOR SUBSIDIZED CHILD CARE

CONTINUING SERVICES
300% FY 2009 Federal Poverty Level or 85% District Median Income
Family Size Maximum Gross Annual

Income
1 $ 31,634
2 $ 41,368
3 $ 51,101
4 $ 60,835
5 $ 70,569
6 $ 80,302
7 $ 82,127
8 $ 83,952
9 $ 85,777
10 $ 87,602
APPENDIX 7
CALCULATION OF PARENT’S INCOME
PAY SCHEDULE ______________
NAME OF CUSTOMER ______________________________
All pay statements used for verification of employment must be the ORIGINAL document and must be current within the past 30
days. If several documents are presented, at least one must be dated no more than thirty (30) days prior to the date of the eligibility
determination.
The two most recent consecutive pay statements should be submitted. In cases where the customer has a variable work schedule, an
average salary is computed from the several statements. However, if the customer has a regular schedule of hours, such as 40 hours
per week, the salary computation should be based on the regular earnings for that tour of duty, even though every pay statement may
not reflect a full schedule.
Select appropriate schedule:
□ Monthly pay x12 months □ Weekly pay x 52 weeks □ Bi-Weekly x 26 weeks □ Bi-Monthly x 24 months
All income is converted into a yearly figure.
Gross Amount Pay Date
1.) $ _______________ __________________
2.) $ _______________ __________________
Total $ ________________ divided by 2 $________________ x ____ = A) $_____________________
OTHER COUNTABLE INCOME _____________________ B) $_____________________

Source
TOTAL ANNUAL GROSS INCOME (add A + B) C) $_____________________
Minus DEDUCTION (If none enter $0)

(Check source) D) $_____________________
□ Private Child Care $ _______________
□ Child Support $ _ _____________
□ Child w/ Disability $ _______________
Adjusted Annual Gross Income (subtract D from C) E) $______________________
FAMILY SIZE _____________________

Find parent co-payment on the fee scale. Fees should be assigned in order from the youngest receiving subsidized child care to the
oldest.
Child 1 _____________________________ Parent fee ____________ Other Fee________________
_____________________________________________ ________________________________
Eligibility Worker Signature Date
CALCULATION OF PARENT’S INCOME (10 Month Employee)
PAY SCHEDULE _____________________
NAME OF CUSTOMER ______________________________
All pay statements used for verification of employment must be the ORIGINAL document and must be current within the past 30
days. If several documents are presented, at least one must be dated no more than thirty (30) days prior to the date of the eligibility
determination.
The three most recent consecutive pay statements should be submitted. In cases where the customer has a variable work schedule, an
average salary is computed from the several statements. However, if the customer has a regular schedule of hours, such as 40 hours
per week, the salary computation should be based on the regular earnings for that tour of duty, even though every pay statement may
not reflect a full schedule. Select appropriate schedule for 10 month employee:
□ Monthly pay x10 months □ Weekly pay x 44 weeks □ Bi-Weekly x 22 weeks □ Bi-Monthly x 20 months
All income is converted to a yearly figure.
Gross Amount Pay Date

1. $ ___________________ _____________________
2. $ ___________________ _____________________
Total $ ________________ divided by 2 $_______________ x ____ = A) $_____________________
OTHER COUNTABLE INCOME _________________________ B) $_____________________

Source
TOTAL ANNUAL GROSS INCOME (add A + B) C) $_____________________
Minus DEDUCTION (If none enter $0) D) $_____________________
(Check Source)
□ Private Child Care $ ____________
□ Child Support $ ____________
□ Child w/ Disability $ ____________
Adjusted Annual Gross Income (subtract D from C) E) $______________________
FAMILY SIZE _____________________

Find parent co-payment on the fee scale. Fees should be assigned in order from the youngest receiving subsidized child care to the
oldest.
_____________________________________________ ________________________________
Eligibility Worker Signature Date
APPENDIX 8
APPENDIX 9
PARENT FEE CHANGE FORM
Date: ______________________________
Dear _________________________________________:
Child Care Home Provider/Center Director
To confirm our contact on _______________ with ____________________________________

Name of Parent
Concerning ____________________________________________________________________
Name of Child (ren)
Our records indicate the following changes:
[ ] Change in Parents Daily Rate
From $__________ to $_______ / $___________ for child #1 _________________

B/A Full Day
From $__________to $________/ $___________for child #2 _________________

B/A Full Day
[ ] Change of Child Care Worker from___________________ to _________________
Effective date of action _______________________
[ ] Termination Effective Date of Action _________________________
Parent Signature ____________________________ Date_________________________
Please be advised that this will be your only notification.
Thank you for the services you render to provide child care and early education to our children.
Eligibility Worker: Telephone: Email:
Orig - Provider
1 copy - Parent
1 copy - Case file
APPENDIX 10
ELIGIBILITY REVIEW APPOINTMENT LETTER
Date:
Dear:
This is to advise you of your eligibility review in order to determine your continued eligibility to receive child care
services, as required by the Office of the State Superintendent of Education. Your scheduled appointment is
Date:
Time:
Place:
Please bring the following information with you to this review:
____ Two most recent consecutive pay statements (original documents only)
____ Verification of any other source of income (TANF, SSI, Child Support, Spouse's income, etc.)
____ Statement from school or training site verifying your enrollment and attendance, officially prepared by the
proper source (stating schedule, duration and type of program)
____ Information to verify that you reside at your current address (i.e., phone bill, utility bill - gas/electric, official
rent receipt, etc.) or a notarized letter from your landlord, homeowner, or someone you live with and two
current pieces of mail with your name and address (original documents only)
____ Other Health Certificate Form(s)
____ Other documentation to support your need for child care (ex: special needs classification, referral from another
agency)
All documents must be current within the past 30 days.

If any of the checked items do not apply to your situation, please call your worker.
THIS WILL BE YOUR ONLY APPOINTMENT NOTICE. Should you be unable to keep this appointment, please
call the office immediately to arrange another appointment. If we do not hear from you, your services will be
terminated on _________________________________
Sincerely,
Eligibility Worker ________________________________ Telephone # _____________________
Original - Parent/Guardian Copy - File

APPENDIX 11
NOTICE OF TERMINATION OF CHILD CARE SERVICES
Date: ___________________________
To: ___________________________
Parent/Guardian
___________________________
Provider
From: ___________________________ Signature _________________________

Eligibility Worker
Eligibility worker telephone number _____________________________
This is to notify you that child care services for: ____________________________

Child’s Name
____________________________
Child’s Name
____________________________
Child’s Name
will be terminated effective _________________. The reason for termination 1 is
______________________________________________________________________
If you disagree with the above action you may request a fair hearing. If you request a fair hearing before the effective
date of this action listed above, your child care benefits will continue uninterrupted until hearing decision is made. If
you do not request a fair hearing before the effective date of this action, you may within 90 days from the date of the
notice of the action request a hearing, but you will not continue to receive benefits while the hearing is pending. A
hearing decision will be rendered within 60 days of your request. Your request must be made in writing to the Office of
Administrative Hearings, 441 4th Street, N.W., Suite 450-North, Washington D.C. 20001.
If you request a fair hearing, you (1) have the right to be represented by legal counsel or by a lay person who is not an
employee of the District; (2) may bring witnesses on your behalf; (3) reasonable expenses related to the hearing, such as
transportation costs for you or your witnesses, will be paid by the Mayor; and (4) legal services are available to you.
1
Except in the case of request by parent or guardian, termination of services may be issued for failure to comply with
the following laws and regulations governing child care services including The Day Care Policy Act of 1979, effective
September 19, 1979 (D.C. law 3-16; D.C. code, sec. 3-301, et. Seq.), as amended; The Child Care Services Assistance
Fund Act of 1988, effective January 6, 1989 ( D.C. Law 7-220); current Child Care Development Fund State Plan;
Child Care Subsidy Eligibility Manual.
Distribution – Original in case file

copy to provider
copy to customer
APPENDIX 12
OFFICE OF THE STATE SUPERINTENDENT OF EDUCATION
ELIGIBILITY MONITORING UNIT
LEVEL [ ] PAYMENT SUMMARY ERROR REPORT
[ ] TRADITIONAL [ ] NON TRADITIONAL
NAME OF PROVIDER AND SITE: _________________________________ PERSON COMPLETING FORM: _____________________________

(PLEASE PRINT NAME) (PLEASE PRINT)
TELEPHONE NUMBER: ________________________________ REPORTING MONTH: ______________________________________

(AREA CODE)
DATE: _________________________________________
CHILD'S NAME CHILD'S SSN ELIGIBILITY DATE CHILD Status of Attendance COMMENTS
WORKER’S ENTERED (Use Codes Below)
NAME Child Attending Terminated
Y/N (List Date)
This report must be submitted to OSSE.ErrorReportSubmission@dc.gov or faxed to 1(800) 521-8385.

CODES: Enter the appropriate code for each child in the comments section. Follow the instructions listed for each code.
01 - Never Paid (Always attach the child care admission form).
02 - Partial Payment (In the comments section, enter the time period for which you were not paid - include month, date, and year).
03 - Termination (Be sure that the full date of termination - the month, date and year - is listed in the appropriate section of the "Status of Attendance").
NOTE: Error reports will be returned if they are not fully completed. See Instructions on Back
Level [ ]: Indicate whether the provider is Level I or Level II
Name of Provider: List name of Child Care Center/Family Child Care Provider/Relative Home Care Provider/In-Home Care Provider.
Person Completing Form: Indicate the name of the person completing the error report.
Telephone Number: Indicate telephone number of provider and any other telephone number where the person completing the error report can be more easily reached.
Reporting Month: Indicate current month of payroll.
Date: Indicate date that the error report is being completed.
Child’s Name: Please ensure that the child’s name is spelled correctly as written on the child care admission form (including all hyphens and accents). If the child’s
name is incorrectly spelled on the child care admission form, write a notation in the comment section.
Child's SSN: Please ensure that the child’s social security number is written correctly. Social security numbers are used to identify the correct child. If the child’s
social security number is unknown (000-00-0000), then also enter the parent’s name and social security number in the comment section.
Eligibility Worker’s
Name: Indicate the name of the eligibility worker listed on the child care admission form or the most recent eligibility worker assigned, if known. Write
“Provider” if the eligibility was done at the child care center.
Date Child Entered: Enter the child’s date of admittance. If the child had multiple periods of enrollment with breaks in attendance, then enter the most recent entry date
(date of admittance listed on the most recent child care admission form received).
Status of Attendance: Indicate whether the child is currently attending by writing yes (Y) or no (N).
If the child no longer attends, indicate the termination date (month, day, and year)
Comments: Enter the code that applies to each child. You may also use this section to provide any additional information that may provide clarity to the situation.
Codes: Codes are provided so that you can briefly communicate to us the payment status of each child listed on the error report. Enter (in the comment section)
the code that applies to each child.
REMINDERS: Error Reports: Error reports are due the last day of each month.
Payments: Payment received is always for the previous month. For example, if a child enters the child care center in January you will not receive
any payment for the child until February.
Terminations: All terminations must be reported to the assigned eligibility worker. Terminations must also be listed on the attendance report. If you
have already reported the termination and you continue to be paid for the child, you must report that child on the error report.
APPENDIX 13
ELIGIBILITY CHECK LIST
WORKING PARENT
INTAKE
Customer Name: ______________________________________________________________
SSN (optional): __________________________________ Date: __________________________

(Date of Eligibility Determination)
Prescreening Intake Follow up

Application / Applicant's Signature / Worker's Signature
Admission Form (Signed by Parent)
Admission Form (Signed by Provider)
Health Certificate / Child (Shot records are not acceptable)
Adoption Papers, Legal Custody Order
Birth Certificate / Child(ren) (Full Size Only)
Acceptable Documents of the Child’s Legal Status
Social Security Card / Child(ren) / Self / Spouse (optional)
Picture ID
Record of Case Action
Income Calculation Sheet
Proof of Income / 2 Most Recent Pay Stubs / Child Support

/Vet. Benefits/ Social Security
Proof of Income / Other _________________________
Proof of Private Childcare Deduction
Proof of Dependent College Education
Proof of Residence / Notarized Letter with 2pc mail / Official

Rent Receipt / Phone / Utility Bill
Proof of Residence / Other
Payment Change and Termination Authorization (598)
Work Schedule (Nontraditional Only) (If you requested Non-traditional hours

which are before 7:00 a.m. or after 6:00 p.m., overnight, Saturday or Sunday
Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………...
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
Staff/ Eligibility Worker’s Signature
Prescreening: ____________________________ Date: _______________________
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
JOB TRAINING
INTAKE
Customer Name: ______________________________________________________________

Application / Applicant's Signature / Worker's Signature Prescreening Intake Follow up

Health Certificate /(Shot records are not acceptable)
Picture ID

Proof of Activity / Letter from program or School / Receipt of
Payment Change and Termination Authorization (598
Work Schedule (If you requested Non-traditional hours which

are before 7:00 a.m. or after 6:00 p.m., overnight, Saturday or Sunday)
Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
UNDERGRADUATE PROGRAM
INTAKE
Customer Name: ______________________________________________________________

Proof of Activity / Letter from program or school / Receipt of payment
Picture ID


Work Schedule (If you requested Non-traditional hours which

are before 7:00 a.m. or after 6:00 p.m., overnight, Saturday or Sunday)
Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………...
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
FOOD STAMPS EMPLOYMENT/TRAINING PROGRAM

INTAKE
Customer Name: ______________________________________________________________

Childcare Referral (ESA)

Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
TANF RECIPIENTS
INTAKE
Customer Name: ______________________________________________________________

Childcare Referral (IMA)
Health Certificate / (Shot records are not acceptable)
Picture ID

Comments:
………………………………………………………………………………………………………….
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
TANF PAYEE
INTAKE
Customer Name: ______________________________________________________________

Picture ID
Proof of Employment / Training
ACEDS Printout or Letter from ESA Worker
Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
TEEN OR YOUNG ADULT PARENT

INTAKE
Customer Name: ______________________________________________________________


Picture ID
Proof of Activity / Letter from program or School
Proof of Residence / School Print-Out
Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
JOB SEARCH
INTAKE
Customer Name: ______________________________________________________________

Childcare Referral (Approved Job Search Program)
Picture ID

Comments:
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
CHILDREN UNDER PROTECTIVE SERVICES

INTAKE
Customer Name: ______________________________________________________________

Childcare Referral / CFSA
Follow Up Form (YES or NO)
Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………...
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
CHILD WITH SPECIAL NEEDS

INTAKE
Customer Name: ______________________________________________________________
SSN (optional): ______________________________ Date: __________________________

Picture ID

Proof of Medical expenses associated with child with special needs
Proof of Disability / Letter from Physician / IEP / IFSP / Developmental Evaluation


Comments:
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
CHILDREN EXPERIENCING HOMELESSNESS

INTAKE
Customer Name: ______________________________________________________________

Childcare Referral
Follow Up Form (YES or NO)
Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………...
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
FOSTER CARE
INTAKE
Customer Name: ______________________________________________________________


Childcare Referral / CFSA
Proof of Employment
Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………...
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
ADULT WITH A DISABILITY

INTAKE
Customer Name: ______________________________________________________________
SSN (optional): _______________________ Date: __________________________

Picture ID
Proof of Disability / Letter from Physician specifying need for child care (Adult)

Vet. Benefits/ Social Security

Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………...
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

APPENDIX 13
VOCATIONAL REHAB
INTAKE
Customer Name: ______________________________________________________________

Childcare Referral / Letter (Vocational Rehab)
Picture ID



Comments:
………………………………………………………………………………………………………….
…………………………………………………………………………………………………………..
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
………………………………………………………………………………………………………….
Intake: ___________________________________ Date: _______________________
Follow up: ________________________________ Date: ________________________

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Eligibility Determinations for

Subsidized Child Care Policy Manual

Section 100 – General Provisions

Section 200 – Eligibility for Subsidized Child Care

Section 300 – Eligibility Determination and Placement Process

Section 400 – Family Co-Payment

Section 500 – Redetermination of Eligibility

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 2

Section 700 – Appeal and Administrative Hearings

Section 800 – Payments to Providers

Section 900 - Glossary of Key Terms …………………………………………. 58

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 3

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 4

 Identification of factors that constitute eligibility for subsidized child care;

 Identification of appropriate documentation for eligibility decisions;

 Placement of children in an appropriate child development facility;

 Determination of proper subsidized co-payment calculations;

 Redetermination of eligibility or termination of eligibility; and

 Payments made to child development facilities caring for eligible children.

 District of Columbia’s CCDF State Plan, current version;

 Any other relevant OSSE policy issuances.

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 5

100.1 ROLE OF THE OFFICE OF THE STATE SUPERINTENDENT OF EDUCATION

100.2 ROLE OF ELIGIBILITY STAFF

(2) Assist with appropriate placement for eligible children; and

100.3 CONFIDENTIALITY OF INFORMATION

100.4 NON-DISCRIMINATION POLICY

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 6

100.5 OSSE DEL MANAGEMENT INFORMATION SYSTEM

100.6 CASE RECORD REQUIREMENTS

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 7

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 8

200.1 ELIGIBILITY REQUIREMENTS

200.2 ELIGIBILITY REQUIREMENT: IS THE CHILD THE APPROPRIATE AGE?

200.3 ELIGIBILITY REQUIREMENT: DOES THE APPLICANT HAVE A VALID

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 9

200.4 ELIGIBILITY REQUIREMENT: IS THE CHILD A CITIZEN OR HAVE LEGAL

200.5 ELIGIBILITY REQUIREMENT: IS THE CHILD A RESIDENT OF THE

(a) Child Experiencing Homelessness. If an eligibility staff member identifies or an

(b) Additional Residency Confirmation – Tax Deduction. If an applicant submits a

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 10

(2) If a review of eligibility is being completed, the correction must be

(2) Child under Protective Services. A child under protection of the DC

200.6 ELIGIBILITY REQUIREMENT: HAS THE APPLICANT DEMONSTRATED A

ELIGIBILITY DETERMINATIONS FOR SUBSIDIZED CHILD CARE POLICY MANUAL 11

WORKING OR ATTENDING A JOB TRAINING OR EDUCATION PROGRAM

Training The eligibility staff shall confirm the training program

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Preliminary Training. A basic training provided before

Job Training. Acceptable job training program shall:

(1) Provide instruction in specific job skills (i.e. computer

Undergraduate A student attending either:

Participants in This group of applicants participates in a qualifying activity for a minimum of

TANF This group of applicants includes TANF recipients participating in a

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(2) A child shall reside with parent(s) or guardian(s) who is seeking

SEEKING EMPLOYMENT OR ENGAGING IN JOB SEARCH

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RECEIVE, OR NEED TO RECEIVE, PROTECTIVE SERVICES,

Children eligible for child care pursuant to this subsection are:

Children This group of applicants represents children who are experiencing

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Adoptive parents (transitioning from guardianship status) are included in this