Workforce Solutions Child Care Services (CCS) Eligibility Requirements (Local Calls) (Long Distance)

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1 Dear Parent: Workforce Solutions Child Care Services (CCS) Eligibility Requirements (Local Calls) (Long Distance) If you need assistance in paying for daycare and meet the basic eligibility requirements listed below, please contact CCS immediately so that we may process your child care. Household requirements: Parents must be employed, in school or in training A minimum of 25 hours per week for a single parent A minimum of 50 hours per week for a two parent household Household must meet income guideline for family size (see income guidelines below) Documents for you and all household members: Birth Ce cates Social Security Cards (Optional - SSN is voluntary and not a requirement to receive Child Care Services) Driver License for parents If employed: Copies of last (4) four checks stubs for each parent in the household Veri ca n of Work Schedule Household income: Proof of all other household income/bene ts (i.e., Unemployment, Temporary Assistance for Needy Families) If training: Current school schedule and current transcript. If a ending high school/ged program or a Voca onal school, a current le er of enrollment from your school. Veri ca n of School or Training Schedule Compliance with Parent Responsibility Agreement Child Support: If you have an a ve child support case with the O ce of A orney General (OAG), you must provide proof that your case is open along with a copy of the payment history, or provide documenta on from OAG that your case was suspended or closed. If you have your CIN number, you may use it to print your child support information from the Attorney General s website If receiving Parental Contribu on: Complete the Parent Responsibility Agreement Informal Child Support Form. INSTRUCTIONS: You can mail, fax, or drop off required documents to one of the following o ces. WFS Mission Office 901 Travis St., Suite 7 WFS Weslaco Office 1600 N. Westgate, Suite 400 Mission, Texas Weslaco, Texas Fax Number: Fax Number: Once we receive your informa n, a CCS Advisor will contact you to process your child care. Please make sure to provide us with your home, work, school, cell and any other phone number where we can contact you. Thank you. Eligibility Code Card for Child Care Services E ec ve October 1, 201 through September 30, 201 Family Size Monthly 85% SMI 2 $3, 3 $3, 4 $4, 5 $5, 6 $6, 7 $6,3 8 $6, 9 $6, 10 $6, 11 $6, 12 $7, 13 $7, 14 $7, 15 $7,

2 Eligibility Packet Guide Checklist Please use this checklist as a guide to help you complete the eligibility renewal packet. All of this information may be mailed, faxed or dropped off to our office. You may go to your nearest Workforce Solutions Center to use a computer, printer or fax machine free of charge. For assistance and/or to locate the WFS Office nearest you, please call (877) or visit. RETURN ALL FORMS TO CHILD CARE SERVICES (CCS) BY THE DEADLINE INDICATED ON THE COVER LETTER. FAX: (WFS Weslaco Office) or (WFS Mission Office) Mail or Drop Off: WFS Weslaco Office WFS Mission Office 1600 N. Westgate, Ste Travis St., Suite 7 Weslaco, Texas Mission, Texas (Toll Free) Parents Guide to Child Care Services Overview Please read this form and keep for your records. Frequently Asked Questions Please read this form and keep for you records. Child Care Eligibility Certification Form This form is your official certification document. By completing this form, you are certifying that the information on this form is complete and accurate. If this form is not complete and accurate child care assistance will not be authorized or may be denied. You must ensure that this document: Does not have any white out corrections. Is NOT written in pencil but in BLUE or BLACK ink Has all information that is applicable, completed Is signed and dated (date should be the day you submit the application) All income, school and training verification must be current Parent Acknowledgment of Rights and Responsibilities This form details what you rights and responsibilities are while receiving assistance. Please make a copy and keep for your records. It outlines: Your rights and responsibilities Your reporting of changes responsibilities and consequences for not reporting changes with in 10 days of occurrence. Fraud and Abuse of program services regulations Attorney General Verification of Child Support Necessary if you do not have an informal arrangement with the non-custodial parent Texas law requires that anyone who receives child care assistance through certain funds must be actively pursuing child support, have all children under 18 years of age attending public school as required by the Texas Education Agency, and parents not abusing illegal substances. If you do not have an informal arrangement with the non-custodial parent (see below), Child Care Services must have verification that you have applied or a print out of your case history for each child. The Office of the Attorney General has an interactive parent portal that allows you to apply online and print off your payment information. The website is If you do not have an open case with the Texas Attorney General s office, then you may provide a copy of one of t he following documents: Child Support through a private agency we must have a printout from that agency that shows a current child support payment history for each child. Confirmation of Child Support Interactive Print Screen If you have an informal agreement with the non-custodial parent, please see Informal Child Support Agreement Form. Orientation to Complaint Form This form provides the parent with an orientation on complaint procedures. Please sign and date form Informal Child Support Agreement Form please find the enclosed form titled Parent Responsibility Agreement/Informal Child Support Form Please make copies of this form, if necessary. Both the custodial AND non-custodial parent of EACH child are required to sign and date this form and return to us. Again, each non-custodial parent must sign and document the payment history. Please Note: Child Support does not have to be a monetary/financial amount; it can be any contribution that the non-custodial parent is providing for the welfare of the child. Verification is required. Note: You do NOT have to return if you have an open child support case with the office of the Attorney General or you have applied.

3 Parents Guide to Child Care Services Overview Applying For Child Care Services Your Rights: You have the right to have someone represent you. You may ask for help when you apply for child care services. You may ask for help nding out what quality child care is. You may trust that the informa on you give us is con d Your Responsibilities: You must meet the income limits for your family size. You must be in an edu onal program, job training, or employed a minimum numbers of hours per week to be eligible for these services: Single parents 25 hours, two-parent family 50 hours. You must be able to prove zenship and age for the children receiving assistance. You must meet all the requirements as outlined in the Parent Responsibility Agreement. This includes child support for each child living in your household, acceptable public school a endance, and not abusing illegal substances. Note: Must be in compliance at the Eligibility Renewal (recertification) You must live in Hidalgo, Willacy or Starr Coun es. You must provide income veri ca on or veri ca on of enrollment in school or training. You must provide the informa on we request to help us determine your eligibility for child care services You must sign the forms we ask you to sign You must return all requested forms by the deadline date we ve provided Enrolling Your Child Your Rights: You have the right to use any regulated child care provider or an eligible rela ve provider. You may and should visit the child care provider before you decide where you want your children to go Your Responsibilities: You are responsible for the quality of care from the provider you choose. You must call us at least 5 days before transferring your child to a di erent child care provider.

4 Using a Child Care Provider Your Rights: You may request to move your child to a di child care provider. You may visit your child any me during the day. Your Responsibilities: You must follow our rules and the child care provider rules or your child care services will end. You must respect the provider s star ng and closing hours and pick up your child on me If your child rides a bus to and from child care you or someone else must be at home when the bus picks up or brings home your child You must report any safety or health problems at the child care provider that could harm the children in care to the Department of Family and Protec ve Services ( ) If Your Child Is Absent From Care You must call the child care provider when your child will be absent and state the reason for the absence. Report absences or ill days to CCAA Your child is only allowed to be absent/non swipes for 45 days in a 12 month period Your child s care will end if your child is absent for 5 or more days of care in a row and you do not call the child care provider during that me to explain why your child is absent. Paying Your Child Care Fees You must pay the fees in advance, directly to the child care provider, before receiving child care. Any child care help that you receive from another agency must be reported to Child Care Services The fee you must pay for child care is based upon household income and the number of children receiving assistance The child care fee must be paid, even when your child is absent You must pay any over me charges you are billed due to picking your child up late at the child care provider. if the child care provider is closed, you must pay for holiday child care yourself if you do not pay child care fees, your child care services will end. How to Contact Us Child Care Services WFS Mission Office 901 W. Travis Road, Ste. 7 Mission, TX Tel: FAX: WFS Weslaco Office 1600 N. Westgate, Suite 400 Weslaco, TX Tel: FAX:

5 Website: ons.org An equal opportunity program. Auxiliary aids and services are available upon request to individuals with disabili es. For TTD/TTY, please call Relay Texas Failure to report changes will result in the termination of your child care assistance, and you will be responsible for paying back any funds used during this time. This could results in suspected fraud, and additional fact finding to determine if misuse of funds has occurred. Le ng Us Know About Changes Your Rights: We will advise you in ng at least 15 days before your child care services end or are reduced (excep ons include CPS and Workforce Customers.) if funding is limited, your child care may end at any me. You will receive a 30 day no ce prior to ending of care. You may appeal when child care is ended, denied or reduced. We will inform you of how to appeal the ac on JOB LOSS: you have the right to receive a maximum of 28 days to search for employment during a 1 year period (October thru September) if the job loss is reported within 10 days of losing your job Your Responsibilities: You must tell us and the child care provider when you change your address, your telephone number where to contact you in an emergency or if your child care schedule changes. You must report any changes to us with in 10 calendar days from when it happens. If you do not report changes, your child care services will end o A new job, a lost job, or a change in job o A pay raise or other new income o Family changes such as marital status, add onal children, et o Loss of tanf ben o A change in school or training o Any other change in your life which could change your eligibility JOB LOSS: You must contact us within 10 calendar days from the date of job loss in order to be eligible for child care during that me. Please contact your nearest Workforce Solu ons Center for assistance in lo g employment. You must recer y your case informa on with us, showing that your family con nues to be eligible for assistance. You cannot change your child s care provider un you talk with us and have been approved for the transfer. We must tell the provider that you are changing child care facili es, and make sure the parent fee is paid in full.

6 WFS Mission Office WFS Weslaco Office 901 W. TRAVIS ST., SUITE N. WESTGATE, SUITE 400 MISSION, TEXAS WESLACO, TEXAS FREQUENTLY ASKED QUESTIONS Who qualifies for Child Care Assistance? Anyone living in Hidalgo, Starr or Willacy County, meeting the income guidelines and working, attending school or enrolled in a training program or doing a combination of both for at least 25 hours a week for a single parent and 50 hours a week for a two parent household can qualify for Child Care Assistance. If I am eligible for Child Care Assistance, will I have to pay part of the child care costs myself? Yes, depending on your monthly employment income before taxes (gross amount) and total household income which may include but is not limited to: Child Support, TANF, etc. as well as your family size. You will be responsible for your parent share of cost also known as your co-pay. How do I apply? You can complete the attached packet and either fax or drop off at one of the following centers. West Hidalgo Workforce or East Hidalgo Workforce Fax: Fax: How do I choose the right child care? We are a provider choice program where parents have the option to choose their own provider. You can refer to the Consumer Guide brochure located in your packet for more information. If you would like assistance in choosing a provider please visit child care Licensing/. You can also call for further information. Please keep in mind that provider must be licensed or registered with the State of Texas or can be an eligible family member.

7 Do I have to pursue child support from the father/mother of my child (ren) if s/he does not reside with us? Yes. One of the requirements to be able to receive assistance is that you must be actively seeking child support for all of your children living in your household under the age of 18. You must have an open case with the Attorney General s O ce or an Informal Child Support agreement with the non-custodial parent if they are contributing to the welfare of the child (ren) on a monthly basis. I am having trouble paying my co-payment, are there options available to assist me? Fee reductions are available for unexpected expenses. You will need to provide receipts, invoices, or other documents to support your unexpected expense and a CCS Specialist will determine approval. I lost my job but I am currently seeking employment. Would I still be eligible to receive assistance? You will have to report your job loss within 10 calendar days of the last day of employment. We offer child care assistance while seeking employment for up to 28 days. We offer one job search per year. For more information please contact CCS at West Hidalgo Workforce at or East Hidalgo Workforce at I am about to have a new baby! Do I need to report my new baby before or after I go on maternity leave from my job? You will need to report your change within 10 calendar days from the last day you worked to request an Incapacitation. We offer 60 days for a medical leave but you must send in medical documents from your doctor and your employer verifying dates of your absence and date you are expected to return to work.

8 Who can be included in the total number of person in my household? The number of person in your household includes yourself and your dependants under the age of 18 or dependent that you have legal custody of that are attending school, your spouse, or the other father or mother of the children o Note: a dependent can be defined as anyone that you are legally able to claim on your tax return How is my co-pay determined? Your monthly co-pay amount is determined by your monthly employment income before taxes(gross amount) and total household income which may include but is not limited to: Child Support, TANF, etc. as well as your family size and number of children receiving care. Are my rent, electricity, car note, and other expenses taken into consideration when determining my co-pay? Unfortunately no. Your co-pay is based solely on your monthly employment income before taxes (gross amount) and total household income which may include but is not limited to: Child Support, TANF, etc. as well as your family size and the number of children receiving care.

9 TWIST ID#: CHILD CARE ELIGIBILITY CERTIFICATION FORM 1.Applicant Name (First, MI, Last) / Nombre: (Inicial, apellido) Social Security (optional) / Número de seguro social (opcional) Date Of Birth / Fecha de nacimento Physical Address / Dirección del Domicilio City / Ciudad: Zip Code / Código postal County / Condado Mailing Address / Dirección postal City / Ciudad Zip Code / Código postal Sex: M F Sexo M F Home Phone # / Teléfono del hogar Cell Phone # / Teléfono celular Other Contact # w/name and Relation / Teléfono alternativo, nombre y relación: Are you a Veteran or Spouse of a Veteran? Yes No Es usted es veterano o esposo/a de un veterano? Si No Address / Correo Electrónico Foster Youth Yes No Hijos adoptivos Si No Marital Status: ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed Migrant Yes No Migrante Si No Food Stamps Yes No Highest Grade Completed / Nivel de educación Family Size Número de miembros que componen la unidad familiar: Race / Raza Estado civil: ( ) Casado ( ) Soltero ( ) Divorciado ( ) Separado ( ) Viudo ( ) 2.Name of Second Parent in Household / Nombre del segundo padre que está en casa Recibe estampillas? Si Other Household Members / Otros Miembros Del Hogar No Social Security # (optional)/ Número de seguro social (opcional) Date of Birth / Fecha de nacimento Name(s) Please write in name as shown on social security card Nombre(s) Por favor, escriba el nombre como se indica en la tarjeta de seguro social Relation Relación Birth Date Fecha de Nacimiento Sex Sexo Ethnicity Raza Social Security# (optional) Número de Seguro Social (opcional) Child Care Requiere cuidado? Child with Special Needs Es niño(a) con necesidades especiales? 3. M F Y/SI No Y/SI No 4. M F Y/SI No Y/SI No 5. M F Y/SI No Y/SI No 6. M F Y/SI No Y/SI No 7. M F Y/SI No Y/SI No 8. M F Y/SI No Y/SI No 9. M F Y/SI No Y/SI No ( ) Workers Compensation / Compensación a los Trabajadores $ Other Household Income (include monthly amount) / Otros Ingresos al Hogar (Cantidad Por Mes) ( ) Child Support / Manutención de Hijos $ ( ) Social Security Benefits (SSA) / Beneficios de Seguro Social $ SSI Y/SI No Y/SI No Y/SI No Y/SI No Y/SI No Y/SI No Y/SI No Grade School Grado Escolar ( ) Veteran s Benefits / Beneficios de Veterano $ ( ) Supplemental Security Benefits (SSI) / Beneficios de Seguro Suplementario (SSI) $ ( ) Unemployment Compensation / Desempleo $ ( ) TANF $ ( ) Other / Otro: $ Day Care Name: DC License #: Phone Number: Nombre de Proveedor Numero de Licencia Numero de Teléfono Applicant Signature / Firma Del Solicitante: Date / Fecha:

10 TWIST ID#: CHILD CARE ELIGIBILITY CERTIFICATION FORM Employment / Education / Training Empleo / Educación / Entrenamiento Employer Name / Nombre del empleador & Start Date / Fecha Que Empezó Empleo Employer Address/ Dirección del empleador Job Title / Position / Puesto de trabajo/cargo & Pay Rate / Sueldo por hora Employer Telephone Number Número telefónico del empleador Hours Worked per Week & How Often Paid / Horas trabajadas por semana y con qué frecuencia se le paga Employer Name #2 / Empleado # 2 Nombre del segundo empleador (si aplica) Start Date / Fecha Que Empezó Empleo Employer Address Dirección del segundo empleador Job Title / Position Puesto de trabajo/cargo & Pay Rate / Sueldo por hora Employer Telephone Number telefónico del segundo empleador & Número Hours Worked per Week & How Often Paid / Horas trabajadas por semana y con qué frecuencia se le paga Name of College / School / Training Program Nombre del colegio / escuela / programa de capacitación? College Credit Hours Currently Attending / Horas de crédito Universitario que asiste actualmente College Semester Hours Completed to Date / Horas Universitarias semestre completado hasta la fecha Name of Other School or Training Program / Nombre de la segunda escuela o programa de capacitación Any Degrees or Certificates Currently Obtained (Associates, Bachelors, or Certificates) Tiene algún título académico o documento ya adquirido? (Diplomado, licenciatura, etc) *Self Employed / Type of Business *Negocio propio / Tipo de negocio Applicant s Information Información del Solicitante Second Parent in HH Information Información del Segundo Padre (si está en el hogar) Provide verification for the following ítems for each member of the family, if applicable Proporcione verificación para lo siguiente. para cada miembro de la familia, si es aplicable Gross Wages/Salaries Ingresos Brutos/Salarios Self-Employment Reg Payments SS Act Reg. Wkm Compensation Comp & Disability Payments Interest/Dividends Railroad Retirement Retirment Other Included Income Child Support SSDI Public Assistance Unemployment Benefit Capital Gains/Loses One Time Cash Payment Pago Veterans Active Duty Payment in lieu of TANF Payment from Home Sales Auto Accident Payment Lottery Winnings $600 or greater Pensions, annuities, life insurance and 401K withdrawlas Trabajo por cuenta propia Pagos Reg. Del Seguro Social Compensación Reg. Del Trabajador Pago de Comp. Por Incapacidad Intereses/Dividendos Jubilación Ferroviaria Jubilación Otro Ingreso Incluido Sostenimiento pare Niños Seguro Social *Self-employed customers must complete and submit F1049 with receipts, if applicable along with required self-employment documentation. *Los clientes autónomos deben completar y enviar F1049 y presentar con recibos, si se aplica junto con la documentación requerida autoempleo. Asistencia Publica Compensacion de Trabajadores Ganancias Capitales/Perdidas Pago en Efectivo una sola vez Veteranos de Servicio Activo TANF Pago en lugar de TANF Pago por Venta de Casa Pago debido a Accidente Automotriz Premios de Lotería de $600 o mas Pensiones, anualidades, seguro de vida, plan dejubilicion y retiros de 401K I understand that: (1) a person who obtains or attempts to obtain, by fraudulent means, services to which the person is not entitled may be prosecuted under applicable state and federal laws; (2) I am entitled to be notified about my eligibility for services within 20 calendar days from the date of this application; (3) I, or my representative, may appeal denial, reduction, or termination of services; (4) services will be provided without regard to sex, race, creed, color, national origin, or disability; (5) the information on this application is confidential. By signing this form, I am applying for services from Workforce Solutions or their child care contractor. I give permission to Workforce Solutions or their child care contractor to contact a third party to verify income or family size, and use the social security numbers for identification of Social Security Benefits and income. All Information provided represents a complete and accurate statement of my family s circumstances at the time of application. I agree to report any changes to this information within 10 business days of the change. I understand that social security numbers (SSN) are voluntary and not a requirement to receive child care services. Entiendo que (1)Personas que obtienen o que atentan obtener, por medio ilícito, servicios a personas que no califican pueden ser demandadas bajo las leyes federales y estatales; (2) Tengo el derecho de recibir notificación de mi elegibilidad de servicios dentro 20 días calendarios a partir de la fecha de esta aplicación; (3) Yo, o mi representante, pueden apelar el rechazo, reducción o terminación de servicios; (4) servicios serán dados independiente de raza, sexo, credo, color, nacionalidad, o incapacitación; (5) la información en esta aplicación es confidencial. Al firmar esta forma, estoy aplicando para los servicios de Workforce Solutions o el contratista de cuidado de niños. Le doy permiso a Workforce Solutions o al contratista de cuidado de niños que contacten a terceros para verificar ingresos o la cantidad en la unidad de familia, y el uso de los números sociales para identificar ingresos y beneficios de seguro social. Toda la información proporcionada representa una declaración completa y precisa de las circunstancias de mi familia en el momento de la solicitud. Estoy de acuerdo en reportar cualquier cambio a esta información dentro de 10 días hábiles posteriores al cambio. Entiendo que el número social es voluntariado y no es un requisito para recibir servicios de cuidado infantil. Applicant Signature / Firma Del Solicitante: Date / Fecha: CCS Representative / Firma de Representante de CCS: Date / Fecha:

11 TWIST ID#: CHILD CARE ELIGIBILITY CERTIFICATION FORM ELIGIBILITY DETERMINATION DATA SHEET Customer Name: TWIST Number: Customer Child Care Eligibility Certification Form Date: For Office Use Only Eligibility Dates: Family Size: Gross Monthly Income: Max Allowable Income for Family Size: # Children in Care: Provider Name/ License #/Phone #: Person Receiving Information at DC: Authorization Code: DC Effective Date: Transportation: Care Hours/Days Authorized: Monthly Parent Share of Cost for the 1 st of the Following Month: Parent Share of Cost for the Current Month: Reductions: PT Care - S/C Care - Part Week - Low Income Reduction - Extenuating Circumstance Transitional Dates: Transitional Form on File: 28 Job Search Dates: to Last Job Search Date: Medical Leave Dates: to Documents on File: Education / Training Program with: Start Date: End Date: Were Phone Numbers and Mailing Address Updated In TWIST? Date Form 2450 and Summary Form Mailed: Date PARR/CCAA Form was reviewed with Customer: Data Entry Date: Comments: CCS Rep Signature: Date:

12 Workforce Solutions Child Care Services IMPORTANT Child Support Information Child Care Services no longer has access to the Office of the Attorney General Web Portal, which allowed our agency to verify your formal child support cooperation on your behalf. Eligibility requirements state that in order for you to be eligible for services you must prove that you are actively seeking child support (formal or informal agreements) for all of your children living in your household under the age of 18. It will be your responsibility to provide verification of compliance with this requirement in order to be considered eligible for child care assistance. If you do not have an informal arrangement with the non-custodial parent, you must: Locate the Office of Attorney General nearest you, apply online, or utilize the interactive child support portal for existing cases. Please go online at Verification of the application or payment history will be required by CCS in order for services to be authorized or re-authorized. Please attach your child support verification here and return to CCS. (Please attach all child support verification documents for all children in household)

13 PARENT ACKNOWLEDGMENT OF RIGHTS AND RESPONSIBILITES FOR CHILD CARE SERVICES Parent Name: TWIST #: Please read the information on this form carefully before you and your spouse (if applicable) sign and date. Please contact your child care worker immediately if you have any questions regarding the information or requirements on this form. Please understand that this is temporary funding and can end at anytime if you become ineligible or funding has been exhausted. PARENT ENROLLMENT I understand the available child care services, my rights and responsibilities, and the process to receive and continue the child care services. My spouse (if applicable) and I must: Be in training, education or employment activities for at least 25 hours a week for a single family, and 50 hours a week for a two parent household. Be within income guidelines for my family size. Reside within Hidalgo, Willacy or Starr County. Sign, date and submit all required forms and documents to CCS at least 10 work days before my eligibility end date. Report lost of employment within 10 calendar days of occurrence. I understand that I may be eligible for a 28 day job search activity once a year (October to September) (non-applicable for CPS and Workforce Center customers). Select the child care arrangement that my family is using. I was given information about the different type of child care. (Not available to CPS referred parents.) I understand the requirements of the child care facility. I will meet the enrollment requirements of the child care facility. I understand I must report to Child Care Services within 3 business days, instances in which a parent s attempt to record attendance in CCAA is denied or rejected and cannot be corrected at the provider site. Failure to report such instances may result in an absence counted toward the reimbursement to the provider. I understand a fifteen (15) day notification will not be required and child care will not continue during an appeal if the care was terminated due to five (5) consecutive absences and with no parent contact with the provider or child care contractor. I will provide information including health and immunization records, authorization to secure medical assistance, and parent contact information to be used in case of an emergency. I will be on time and honor the child care facilities starting and closing hours. I will pay any charges incurred if I am late picking up my child. I will report to TDFPS licensing office any possible violation of licensing standards within the child care facility. If I need child care on any of the provider s nine paid holidays, I will make and pay for my own arrangements. I will make other child care arrangements when I am no longer eligible for child care services. I understand childcare providers are prohibited from denying a child care referral based on the parent s income status, receipt of public assistance or the child s Texas Department of Family and Protective Services Child Protective Services (CPS) status. I understand providers cannot charge fees to parents receiving child care services that are not charged to parents who are not receiving child care services. I understand I am only allowed up to three provider transfers per year based on anniversary date. Transfers will be effective on the first of the following month. Exception to the transfer limit and effective start date will be allowed due to child safety issues, provider corrective action or other extenuating circumstances. I release the Workforce Solutions-Child Care Services Contractor, Lower Rio Grande Valley Workforce Development (LRGVWD) Board, and Texas Workforce Commission (TWC) from any responsibility for the quality of the child care services my child may receive from the facility of my choosing. Parent Signature: Date:

14 TWIST#: PARENT RESPONSIBILITYAGREEMENT (PRA) (not applicable to TDFPS and Choices Referrals) I understand that I must be in compliance with the PRA s requirements on child support, substance abuse, and school attendance of my children. I understand that my spouse, if applicable and I Must help establish paternity for my child (ren) and help obtain child support for my child (ren). Must not use, sell or possess marijuana or a controlled substance, or abuse alcohol. Must make sure that each family member younger than 18 years of age attends school regularly, unless the child has a high school diploma or a GED credential, or is specifically exempt from school attendance by Texas Education Code (25.086). Understand that the statements listed above will be reviewed at certification and recertification. Understand that failure of the parent or caretaker to comply with the provisions of the Parent Responsibility may result in denial of child care services. I understand that in order to comply with the PRA Child Support requirement above. I will open a child support case with the Office of Attorney General or provide the PRA-Informal Child Support Form of payments I receive every month. PARENT SELF-DECLARATION I declare that since I was last determined to be eligible to receive child care services my spouse (if applicable) and I have: If 2 nd parent is not in the household, please circle NA (Circle response) Parent Spouse / NA Used, sold, or possessed marijuana or other controlled substance. Yes / No Yes / No If yes, I am currently in or have completed a drug rehabilitation program and have attached documentation from the program. Yes / No Yes / No I have abused alcohol Yes / No Yes / No If yes, I am currently in or have completed a drug rehabilitation program and have attached documentation from the program. Yes / No Yes / No Spouse Signature (if applicable): Date: PARENT SHARE OF COST (Parent Fee) (not applicable to TDFPS, Choices, and SNAP Referrals) I agree to pay my parent share of cost (parent fee) directly to my provider before services are rendered. I understand that I must report to CCS and pay any other child care subsidy I might receive from another agency to the child care facility. I understand that the fee amount is based on my gross monthly income, the number of household members, and the number of children I have enrolled in care. I understand that my share of the cost must be paid, even if my child is absent or is not there for the full month. I understand that if I do not pay the parent share of cost amount specified on the CCS Case Summary Information Form timely, my child care services will be terminated. I understand I must pay the parent s share of cost to my child care provider before services are provided. I also understand that my child care services will be discontinued on the third (3 rd ) late parent fee provider report within a sixmonth period. I understand a mandatory waiting period of thirty (30) days will be required before a parent can reapply or be placed on the waiting list for child care assistance after a child s enrollment has been denied, reduced, suspended or terminated for nonpayment of the parent share of cost. I understand if my parent s share of cost changes due to a change in the family s gross monthly income, the new parent s share of cost will not be effective until the first calendar day of the following month. PARENT RIGHTS I understand that I have the following rights: To appeal denial, reduction, or termination of services. To have my information used to determine eligibility kept confidential. To receive services without regard to race, sex, color, national origin, age, political beliefs, religion, or disability. To be notified in writing at least 15 calendar days before the denial, reduction, or termination of child care services. Parent Signature: Date: Spouse Signature (if applicable): Date:

15 TWIST #: PARENT AWARENESS I understand that I must be in training, education or employment activities at least 25 hours a week for a (1) parent household or 50 hours a week for a (2) parent household. I understand that failure to comply with all CCS Requirements, report changes in my case within 10 calendar days of occurrence, and/or provide true and correct information in my case may result in possible criminal prosecution. My case may be referred to the Local Law Enforcement Office, District Attorney s Office (DA) and/or Office of Investigation (OI) for potential prosecution. I will also be required to pay back 100% of the money that was paid to my provider during the period of ineligibility. I will report the following within 10 calendar days of when the change occurs: If my attendance in training, in school, or at my job stops or falls below the required number of hours per week. If my total amount of income including overtime, bonuses, incentive pay, commission, or an increase in child support or other non-employment income and/or benefits (such as TANF, SSI or child support) changes. If I get married or if there is a change in the number of family members living with me. The receipt or the awarding of any child care funds from other public or private entities; or Any other changes that may affect the child s eligibility or parent share of cost for child care. REPORTING FAMILY INCOME I understand that I must report the following income in the CCS Eligibility Certification Form for purposes of determining eligibility and the parent share of cost: (1) Total gross earnings (2)Net income from self-employment (3)Pensions, annuities, life insurance, and retirement income, and early withdrawals from a 401(k) plan not rolled over within 60 days of withdrawal (4) Taxable capital gains, dividends, and interest (5) Net rental income (6) Public assistance payments (7)Income from estate and trust funds (8)Unemployment insurance (9) Worker s compensation income, death benefit payments and other disability payments (10)Spousal maintenance or alimony (11)Child support (12) Court-settlements or judgments; and (13) Lottery payments of $600 or greater. I understand a mandatory waiting period of thirty (30) days will be required before a parent can reapply or be placed on the waiting list for child care assistance after eligibility was terminated due to failure to report to the Child Care Contractor, within 10 days of occurrence, any changes in the family s circumstances that would render the family ineligible for subsidized care. I understand that the information I provide to Workforce Solutions-Child Care Services to determine my eligibility is subject to validation through cross-checks against state and federal databases; and that I may be asked to provide original documents and participate in face-to-face interviews to verify identity and eligibility for child care services. Failure to comply with this requirement will constitute a voluntary discontinue. PARENT ELIGIBILITY END DATE I understand that in order to continue to receive child care services, I must provide all CCS required forms and documents along with all household income information to Workforce Solutions- Child Care Services on or before my eligibility redetermination end date or my child care will be terminated. I read and understand all the requirements stated above and all my questions have been answered. I understand that a person who obtains or attempts to obtain, by fraudulent means, services to which a person is not entitled may be prosecuted under applicable state and federal laws. Parent Signature: Date: Child Care Specialist Signature: Date:

16 PARENT AGREEMENT FOR USE OF THE Child Care Attendance Automation (CCAA) This policy requires that parents understand and comply with the requirements to use the CCAA card to report daily attendance and absences. I agree to the following: 1. I will use my CCAA card daily to report my child s attendance and absences. Attendance can be reported at a point of service (POS) machine or through an Interactive Voice Response (IVR) telephone system at my child care facility. 2. I will report my child s absences or illness by calling on the same day that my child is out. (Note: This may be done from any phone.) 3. I understand that my child care services can be terminated and I may be held responsible for paying the provider for attendance and absences that are not reported using the CCAA card. 4. I agree to record attendance before (drop off) and after (pick up) care is provided by my child care provider. 5. I understand TWC allows child care providers to refuse to accept my child if I do not record attendance in the CCAA system when I drop off or pick up my child at the facility. 6. I agree that I must report to Child Care Services within 3 business days, instances in which my attempt to record attendance in CCAA is denied or rejected and cannot be corrected at the provider site. I understand that failure to report such instances may result in an absence counted toward the maximum 45 paid absences per year or I will be responsible for paying the provider private pay. Note: When you call your CCS worker, he or she will determine if the noncompliance is due to circumstances beyond your control. 7. I understand I can designate up to three individuals who will assist me in dropping off or picking up my children from my provider, as secondary cardholders to report attendance and absences on my behalf. Note: Secondary cardholders must be at least 16 years old, unless the individual is the child s parent. 8. I agree not to designate the owner, director or assistant director of the child care facility as a secondary cardholder. 9. I agree that the attendance must be done by me (the parent/caretaker) or the secondary cardholder only. 10. I agree that my secondary cardholder and I must use our assigned CCAA card when reporting attendance and absences. Giving my CCAA card or PIN to anyone including the child care provider is a CCAA Violation and my child care services can be terminated and my case suspended for up to twelve months. 11. I understand I am responsible for informing my secondary cardholder of the CCAA requirements and I am responsible for any misuse of the attendance card by my secondary cardholder. 12. I agree to contact my CCS worker if I do not receive my CCAA card within 10 days of receiving child care assistance. 13. I agree to contact my CCS worker immediately if my CCAA card is lost, stolen, misplaced or damaged. 14. I agree to report misuse of the CCAA cards and PINs to Workforce Solutions CCS immediately. 15. I understand that my child care services may be terminated if I exceed the maximum number of 45 paid absences per year. These absences include vacation, illnesses and Z-Days (a Z-Day is defined as an authorized care day for which no activity if reported by the parent through the CCAA system). The forty-five (45) days per year, begin on the enrollment or anniversary date. 16. I understand that my child will not be allowed to receive child care services or be placed on the wait list for thirty (30) days after his or her services have been terminated due to five consecutive absences without parent notification or if I exceed the 45 paid absences. CCS will notify me when my child reaches 50%, and 75% of the allowed absences. 17. I understand that I may request a waiver to continue care if 25 out of 45 absences are due to illness and I can provide CCS with verifiable documentation. By signing below I acknowledge that I have read and understand my responsibilities as a CCS customer. I understand that if I violate the CCAA requirements my child care services can be terminated and I may be prosecuted for fraud. Parent Signature: TWIST: Date:

17 PARENT AGREEMENT FOR USE OF THE Child Care Attendance Automation (CCAA) To report attendance you or your secondary cardholder must: 1. Swipe your card. 2. Key in your PIN and press Enter. Choose Attendance Type (1 = Check-in, 2 = Check-out, 3 = Previous Check-in, 4 = Previous Check-out) Note: Previous Check-in and Check-out allows you backdate attendance for the current or previous day. When this feature is used for a previous Check-In, you must make sure to enter the correct date and time. If this is done incorrectly, your CCAA will lock out and you will not be able to swipe for five (5) days. These non-swipes will be counted as absences. Your child care services will be discontinued when you reach 45 absences. 3. Key in the Child Number and press Enter. 4. Repeat for each child. When finished, press Enter again. To report absences you or your secondary cardholder must: 1. Swipe your card. 2. Key in your PIN and press Enter. 3. Choose 5 = Absence Day. 4. Select Absence Type and press Enter. 5. If not a General Absence type, select a Specific Reason. 6. Key in the Child Number and press Enter. 7. Repeat for the next child. When finished, press Enter again. To report attendance and absences in homes or facilities where there is no POS device, you or your secondary cardholder must use the Interactive Voice Response (IVR): 1. Call from the provider s phone. 2. Enter your card number. 3. Enter your PIN. 4. Follow the instructions. You or your secondary cardholders are responsible for making sure attendance is approved for the day by: 1. Checking the message on the POS machine or receipt after each swipe to see if it is approved. If the response is denied you must inform your provider. If the response is 'Store and Forward' (SAF), you must notify the provider that the transaction was SAF, and The provider will check at the next transaction to see if transaction was successful. 2. If using an IVR, you must listen to the IVR message after each recorded attendance to confirm attendance is approved and follow the same steps above if denied. 3. If attendance is not approved through the POS or IVR for three (3) consecutive days, you will need to notify your CCS worker. Failure to report this may result in absences counted toward the maximum 45 paid absences or you may be responsible for paying your child care provider private pay. 4. To replace a lost, stolen, or damaged card, you must call CCS and report it immediately. Failure to do so will cause your child to accumulate absences. 5. To reset a PIN, you must call the Child Care Attendance Card Customer Service number ( ). 6. When you or your secondary cardholder first receives the CCAA card, please call to select a personal identification number (PIN). You will need to enter the 16-digit card number and the cardholder s date of birth to establish the PIN. By signing below I acknowledge that I have read and understand my responsibilities as a CCS customer. I understand that if I violate the CCAA requirements my child care services can be terminated and I may be prosecuted for fraud. Parent Signature: TWIST: Date:

18 WORKFORCE SOLUTIONS ORIENTATION TO DISCRIMINATION COMPLAINT PROCEDURES FORM (29 CFR Part 37) This Orientation to Discrimination Complaint Procedures Form addresses discrimination complaint procedures for the listed programs and services administered in the local workforce development area by the Workforce Development Board and its Contractors: Workforce Investment Act (WIA) Temporary Assistance for Needy Families (TANF) / CHOICES Supplemental Nutrition Assistance Program Employment & Training (SNAP E&T) Child Care Services (CC) Trade Adjustment Assistance (TAA) and Trade Readjustment Allowances (TRA) THE RECIPIENT OF THE FEDERAL FINANCIAL ASSISTANCE IS: Workforce Solutions Equal Opportunity (EO) Officer: Robert Barbosa 3101 West Business 83 Telephone Number: (956) McAllen, TX Relay Texas: / TTY (Voice) Workforce Solutions shall resolve equal opportunity complaints in a fair and prompt manner. Acts of restraint, interference, coercion, discrimination, or reprisal towards complainants exercising their rights to file a complaint under this procedure are prohibited. This procedure applies to all applicants and participants who have cause to file a discrimination complaint related to activities or programs administered by the Board. If you have an equal opportunity complaint concerning any of these programs, you may submit your written complaint to the Board or Contractor EO Officer, as appropriate. After your equal opportunity complaint has been received, the EO Officer will notify you of the next step in the complaint process. As long as you wish to pursue your complaint, the Board or Contractor will follow the steps described below. You should study the Discrimination Complaint Procedure carefully, and if you feel that the required steps are not being followed, contact the EO Officer. Remember, if you feel you are not being provided enough help at any stage of the complaint process, you should contact: Texas Workforce Commission (TWC) Telephone Numbers: Equal Opportunity Monitoring (512) E. 15 th St., Room 242-T Relay Texas: Austin, TX TTY (Voice) EQUAL OPPORTUNITY IS THE LAW It is against the law for this recipient of Federal financial assistance to discriminate on the following bases: against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA), on the basis of the beneficiary s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following areas: deciding who will be admitted, or have access, to any WIA Title I-financially assisted program or activity; providing opportunities in, or treating any person with regard to, such a program or activity; or making employment decisions in the administration of, or in connection with, such a program or activity. WHAT TO DO IF YOU BELIEVE YOU HAVE EXPERIENCED DISCRIMINATION If you think that you have been subjected to discrimination under a WIA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either: the recipient s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or the Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, DC If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action. PROCEDURES ON HOW TO FILE A COMPLAINT WORKFORCE INVESTMENT ACT (WIA) / TRADE ADJUSTMENT ASSISTANCE (TAA) and TRADE READJUSTMENT ALLOWANCES (TRA): If you think you have been subjected to equal opportunity discrimination under a WIA Title I or a TAA/TRA financially assisted program or activity, you may file a discrimination complaint within 180 days from the date of the alleged violation with either the Board/Contractor Equal Opportunity Officer (or designee) or Director, Civil Rights Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N-4123 Washington, DC If you file your complaint with the Board or Contractor, you must wait until you receive a written Notice of Final Action or 90 days have passed (whichever is sooner) before you can file with the CRC. If the written Notice of Final Action is not issued within 90 days of the day you filed your complaint, you have 30 days following the 90-day deadline to file a complaint with CRC (that is, within 120 days of the day you first filed your complaint). If you receive a written Notice of Final Action on your complaint but are dissatisfied with the decision, you may file a complaint with CRC. However, you must file your CRC complaint within 30 days of receiving the Notice of Final Action. TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) / CHOICES and/or CHILD CARE SERVICES (CC): If you think you have been subjected to equal opportunity discrimination under a TANF/Choices and/or Child Care Services (CC) financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either the Board/Contractor Equal Opportunity Officer (or designee) or the Office of Civil Rights, U.S Department of Health and Human Services (HHS), 1301 Young Street, Suite 1169, Dallas, TX 75202, (214) Those filing complaints on child care services may choose to contact the U.S. Department of Agriculture (USDA), Office of Civil Rights-Southwest Region, Food and Nutrition Services, 1100 Commerce Street, Room 555, Dallas, Texas 75242, (214) If you file your complaint with the Board or Contractor, you must wait until a written Notice of Final Action is issued or until 90 days have passed (whichever is sooner) before you can file with the U.S. Department of Health and Human Services. SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM EMPLOYMENT AND TRAINING (SNAP E&T): If you think you have been subjected to discrimination under a SNAP E&T financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either the Board/Contractor Equal Opportunity Officer (or designee) or the U.S. Department of Agriculture, Civil Rights Office/Food and Nutrition Service, 1100 Commerce Street, Room 555, Dallas, TX 75242, ( ) or USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC (202) If you file your complaint with the Board or Contractor, you must wait either until a written Notice of Final Action is issued or until 90 days have passed (whichever is sooner) before filing with the U.S. Department of Agriculture. Please do not sign this notice until you have read it and understand its contents. By my signature below, I acknowledge this orientation to the discrimination complaint procedure and the statement regarding Equal Opportunity Is the Law. I affirm that I have read the Orientation to Discrimination Complaint Procedure Form and that I have been given the opportunity to ask questions about its contents. I understand that the One-Stop application form is not a job application; rather, it is used to determine my eligibility to receive program services and to meet federal reporting requirements. I further understand that failure to provide the requested information may prevent me from receiving services. Applicant Signature Printed Name Date

19 WORKFORCE SOLUTIONS FORMULARIO PARA LA ORIENTACIÓN A LOS PROCEDIMIENTOS DE QUEJA DE DISCRIMINACIÓN (29 CFR Part 37) Este Formulario para la Orientación a los Procedimientos de Queja de Discriminación explica los procedimientos de queja de discriminación para los programas y los servicios mencionados administrados en el Local Workforce Development Area por el Workforce Development Board y sus contratistas: Workforce Investment Act (WIA) Temporary Assistance for Needy Families (TANF) / CHOICES Supplemental Nutrition Assistance Program Employment & Training (SNAP E&T) Child Care Services (CC) Trade Adjustment Assistance (TAA) and Trade Readjustment Allowances (TRA) Recipiente del apoyo financiero federal es: Workforce Solutions Oficial de Igualdad de Oportunidades (EO): Robert Barbosa 3101 West Business 83 Número telefónico: (956) McAllen, TX Relay Texas: / TTY (Voz) Workforce Solutions resolverá quejas de la igualdad de oportunidades de una manera justa y expediente. Se prohiben los actos de internamiento, de interferencia, de la coerción, de la discriminación, o de la represalia hacia los denunciantes que ejercitan sus derechos de presentar una queja conforme a este procedimiento. Este procedimiento se aplica a todos los aspirantes y participantes que tengan causa para presentar una queja de la discriminación relacionada con las actividades o los programas administrados por el Board. Si tiene una queja de la igualdad de oportunidades referente a cualquiera de estos programas, puede presentar su queja oficial por escrito al Oficial de EO del Board o del contratista, como sea apropiado. Después de que se haya recibido su queja de la igualdad de oportunidades, el oficial del EO le notificará del paso siguiente en el proceso de la queja. Mientras desea perseguir su queja, el Board o el contratista seguirá los pasos descritos abajo. Debe estudiar el procedimiento de queja de la discriminación cuidadosamente, y si se siente que los pasos requeridos no se están siguiendo, póngase en contacto con el oficial del EO. Recuerde que si se siente que no le están proporcionando bastante ayuda en cualquier etapa del proceso de la queja, usted debe ponerse en contacto con: Texas Workforce Commission (TWC) Números telefónicos: Equal Opportunity Monitoring E. 15 th St., Room 242-T Relay Texas: Austin, TX TTY (Voz) LA IGUALDAD DE OPORTUNIDADES ES LA LEY El destinatario de asistencia financiera del Gobierno Federal tiene prohibido por ley discriminar, con base en los conceptos a continuación: discriminar a cualquier persona en los Estados Unidos por motivos de su raza, color, religión, sexo, origen nacional, edad, incapacitación, afiliación o ideología política; discriminar a cualquier beneficiario de programas que cuenten con apoyo financiero a tenor del Título I de la Ley de Inversión en la Fuerza Laboral (Workforce Investment Act o WIA) de 1998, por motivo de la ciudadanía o calidad migratoria del beneficiario en tanto inmigrante legalmente autorizado para trabajar en los Estado Unidos; o por motivo de su participación en cualquier programa o actividad que cuente con apoyo financiero a tenor del Título I de la WIA. El destinatario de tal asistencia no debe discriminar en ninguno de los conceptos a continuación: en decidir quiénes han de ser admitidos o tener acceso a cualquier programa o actividad que cuente con apoyo financiero a tenor del Título I de la WIA; en la provision de oportunidades en tal programa o actividad y en el trato a cualquier personal con respecto al programa o actividad; o en la toma de decisiones de empleo en la administración de tal programa o actividad o con respecto al mismo. QUÉ HACER SI USTED CREE HABER SIDO DISCRIMINADO/A Si cree haber sufrido discriminación en un programa o actividad con apoyo financiado a tenor del Título I de la WIA, puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el Director, Civil Rights Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, D.C Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en la más temprana de las dos fechas) antes de presentar su queja al CRC). Si el destinatario de asistencia federal no le entrega un Aviso de Acción Definitiva por escrito dentro de los 90 días de la fecha de presentación de su queja, usted no tiene obligación de esperar a que el destinatario le expida dicho Aviso para presentar una queja con el CRC. Por otra parte, la queja con el CRC debe presentarse dentro de los 30 días del vencimiento del plazo de 90 días, es decir, dentro de 120 días a partir de la fecha en que presentó su queja con el destinatario. Si éste le entrega un Aviso de Acción Definitiva por escrito con respecto a su queja y usted sigue inconforme con la decisión o resolución, puede presentar una queja con el CRC. Hay que presentarla dentro de los 30 días subsiguientes a la fecha en que recibió el Aviso de Acción Definitiva. INSTRUCCIONES DETALLADAS PARA CLASIFICAR UNA QUEJA WORKFORCE INVESTMENT ACT (WIA) / TRADE ADJUSTMENT ASSISTANCE (TAA) y TRADE READJUSTMENT ALLOWANCES (TRA): Si cree haber sufrido discriminación en un programa o actividad con apoyo financiero a tenor del Titulo I de la WIA o TAA/TRA, puede presentar una queja dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el Director, Civil Rights Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N- 4123, Washington, DC Si presenta su queja con el destinatario de asistencia federal o su contratista, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las dos fechas) antes de presentar su queja al CRC. Sí el destinatario de asistencia federal no le entrega un Aviso de Acción Definitiva por escrito dentro de los 90 días de la fecha de presentación de su queja, usted puede presentar una queja con el CRC. La queja CRC debe presentarse dentro de los 30 días del vencimiento del plazo de 90 días, es decir, dentro de 120 días a partir de la fecha en que presentó su queja con el destinatario. Si éste le entrega un Aviso de Acción Definitiva por escrito con respecto a su queja y usted sigue inconforme con la decisión o resolución, puede presentar una queja con el CRC. Hay que presentarla con el CRC dentro de los 30 días subsiguientes a la fecha en que recibió el Aviso de Acción Definitiva. TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) / CHOICES and/or CHILD CARE SERVICES (CC): Si cree haber sufrido discriminación en un programa o actividad con apoyo financiero a tenor del programa TANF/Choices y/o Child Care Services (CC), puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con la Office of Civil Rights, U.S. Dept. of Health and Human Services (HHS), 1301 Young Street, Suite 1169, Dallas, TX 75202, Si cree haber sufrido discriminación en un programa o actividad con apoyo financiero a tenor de la CC, puede popnerse en contacto con el U.S. Dept. of Agriculture (USDA), Office of Civil Rights, Southwest Region, Food and Nutrition Services, 1100 Commerce Street, Room 555, Dallas, Texas 75242, Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las dos fechas) antes de presentar su queja al U.S. Dept. of Health and Human Services. SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM EMPLOYMENT AND TRAINING (SNAP E&T): Si cree haber sufrido discriminación en un programa o actividad con apoyo financiero a tenor del programa SNAP E&T, puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supuesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de asistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el U.S. Dept. of Agriculture, Civil Rights Office/Food and Nutrition Services, 1100 Commerce Street, Room 555, Dallas, Texas 75242, o USDA, Director, Office of Adjudication and Compliance,1400 Independence Avenue, SW, Washington, DC o llame al Si presenta su queja con el destinatario de asistencia federal o su contratista, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en el más temprano de las dos fechas) antes de presentar su queja al U.S. Dept. of Agriculture. Favor de no firmar sin haber leído este aviso y haber comprendido su contenido. Por mi firma abajo, reconozco esta orientación al procedimiento de queja de la discriminación y la declaración con respecto a que la igualdad de oportunidades es la ley. Afirmo que he leído el Formulario para la Orientación a los Procedimientos de Queja de Discriminación y que me han dado la oportunidad de hacer preguntas acerca de su contenido. Entiendo que el formulario One-Stop no es solicitud para trabajo; se utiliza para determinar mi elegibilidad para recibir servicios de programa y para cumplir con requisitos federales de información. Entiendo también que la falta de proporcionar la información pedida puede evitar que reciba servicios. Firma del solicitante Nombre en letra de molde Fecha EMPLEADOR CON IGUALDAD DE OPORTUNIDAD DE EMPLEO/PROGRAMAS Ayudas auxiliares y servicios están disponibles a petición para individuos con incapacidades Relay Texas: (TTY); (Voz); (Español)

20 If In If INSTRUCTIONS ON HOW TO FILE A COMPLAINT (INSTRUCCIONES PARA PRESENTAR UNA QUEJA) Workforce Investment Act (WIA) you think you have been subjected to discrimination under a WIA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either; the recipient s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or Director of Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123 Washington, DC If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your compliant, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but if you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action. Si cree que ha sido sujeto a discriminación bajo el programa asistido o actividad de apoyo financiero Título I de WIA -, puede presentar una queja dentro de los 180 días a partir de la fecha de la presunta violación, en cualquiera de los siguientes: con el destinatario Oficial de Igualdad de Oportunidades (o la persona designada por el destinatario para ese efecto), o bien, él Director del Centro de Derechos Civiles, (Civil Rights Center-CRC), Departamento de Trabajo de los EE.UU. (U.S. Department of Labor), 200 Constitution Avenue NW, Room N-4123, Washington, DC Si presenta su queja con el destinatario de asistencia federal, deberá esperar a que éste le expida un Aviso de Acción Final por escrito, o hasta que hayan pasado 90 días (la fecha que ocurra primero) antes de presentar su queja al Centro de Derechos Civiles; ver la dirección arriba. Si el destinatario de asistencia federal no le entrega un Aviso de Acción Final por escrito dentro de los 90 días de la fecha de la presentación de su queja, usted no tiene obligación de esperar a que le expidan dicho Aviso de Acción Final para presentar una queja con CRC. Sin embargo, deberá presentar su queja a CRC dentro de 30 días después del vencimiento del plazo de 90 días (es decir, dentro de 120 días a partir de la fecha en que presento su queja con el destinatario). Si le es entregado un Aviso de Acción Final por escrito con respecto a su queja y usted sigue inconforme con la decisión o resolución, usted puede presentar una queja con el CRC. Deberá presentarla dentro de los 30 días subsiguientes a la fecha en que recibió el Aviso de Acción Final. TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) / CHOICES and/or NCP CHOICES: If you think you have been subjected to discrimination under a TANF/CHOICES and/or NCP Choices financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either; the recipient s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or the Office of Civil Rights, U.S Department of Health and Human Services, 1301 Young Street, Suite 1169, Dallas, TX 75202, (214) If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the U.S. Department of Health and Human Services. (45 CFR 80 and 84.) Si cree que ha sido sujeto a discriminación bajo el programa asistido o actividad de apoyo financiero TANF/CHOICES o NCP Choices, puede presentar una queja, dentro de los 180 días a partir de la fecha de la presunta violación, en cualquiera de los siguientes, con él destinatario Oficial de Igualdad de Oportunidades (o la persona designada por el destinatario para ese efecto), o bien, con la Oficina de Derechos Civiles, Departamento de Salud y Servicios Humanos de los EE.UU., 1301 Young Street, Suite 1169, Dallas, TX 75202, (214) Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Final por escrito, o hasta transcurridos 90 días (la fecha que ocurra primero) antes de presentar su queja al Centro de Derechos Civiles; ver la dirección arriba. Trade Adjustment Assistance and Trade Readjustment Allowances (TAA/TRA): you think you have been subjected to discrimination under a TAA/TRA financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either; the recipient s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or Director of Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123 Washington, DC If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your compliant, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action. Si cree que ha sido sujeto a discriminación bajo el programa asistido o actividad de apoyo financiero TAA/TRA, puede presentar una queja, dentro de los 180 días a partir de la fecha de la presunta violación, en cualquiera de los siguientes; con él destinatario Oficial de Igualdad de Oportunidades (o la persona designada por el destinatario para ese efecto), o bien, con él Director del Centro de Derechos Civiles, (Civil Rights Center-CRC), Departamento de Trabajo de los EE.UU., (U.S. Department of Labor), 200 Constitution Avenue NW, Room N Washington, DC Si presenta su queja con el destinatario de asistencia federal, deberá esperar a que éste le expida un Aviso de Acción Final por escrito, o hasta que hayan pasado 90 días (la fecha que ocurra primero) antes de presentar su queja al Centro de Derechos Civiles; ver la dirección arriba. Si el destinatario de asistencia federal no le entrega un Aviso de Acción Final por escrito dentro de los 90 días de la fecha de presentación de su queja, usted no tiene obligación de esperar a que le expidan dicho Aviso de Acción Final para presentar una queja con CRC. Sin embargo, deberá presentar su queja a CRC dentro de los 30 días después del vencimiento del plazo de 90 días (es decir, dentro de 120 días a partir de la fecha en que presento su queja con el destinatario). Si se le entrega un Aviso de Acción Final por escrito con respecto a su queja y usted sigue inconforme con la decisión o resolución, usted puede presentar una queja con el CRC. Deberá presentarla dentro de los 30 días subsiguientes a la fecha en que recibió el Aviso de Acción Final. SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM EMPLOYMENT AND TRAINING (SNAP E&T): If you think you have been subjected to discrimination under a SNAP E&T financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either; the recipient s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or the Civil Rights Office, U.S. Department of Agriculture, 1100 Commerce Street, Dallas, TX 75242, (214) ; or USDA Director of U.S Department of Agriculture, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC (202) If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the U.S. Department of Agriculture. Si cree que ha sido sujeto a discriminación bajo el programa asistido o actividad de apoyo financiero SNAP E&T, puede presentar una queja dentro de los 180 días a partir de la fecha de la presunta violación, en cualquiera de los siguientes: con el destinatario Oficial de Igualdad de Oportunidades (o la persona designada por el destinatario para ese efecto), o bien, con la Oficina de Derechos Civiles, Departamento de Agronomía o Agricultura de EE.UU., 1100 Commerce Street, Dallas, TX 75242, (214) ; u la Oficina de Derechos Civiles, Director del Departamento de Agricultura de EE.UU., Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC , (202) Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Final por escrito, o hasta transcurridos 90 días (la fecha que ocurra primero) antes de presentar su queja al Centro de Derechos Civiles; ver la dirección arriba. CHILD CARE SERVICES (CCS): accordance with 45 CFR 80 and 84, it is against the law for this recipient of Federal financial assistance to discriminate on the following bases: against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of any CCS financially assisted program or activity. The recipient must not discriminate in any of the following areas: deciding who will be admitted, or have access, to any CCS-financially assisted program or activity; providing opportunities in, or treating any persons with regard to, such a program or activity; or making employment decisions in the administration of, or in connection with, such a program or activity. If you think you have been subjected to discrimination under CCSfinancially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either; the recipient s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or the U.S Department of Health and Human Services Office of Civil Rights, 1301 Young Street, Suite 1169, Dallas, TX 75202, (214) , or the U.S. Department of Agriculture (USDA), Office of Civil Rights-Southwest Region, Food and Nutrition Services, 1100 Commerce Street, Dallas, TX 75242, (214) If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the U.S. Department of Health and Human Services. De acuerdo a la sección 45 CFR 80 y 84, es contra la ley de asistencia financiera del Gobierno Federal discriminar con base a los siguientes conceptos: discriminar a cualquier persona en los Estados Unidos por motivos de su raza, color, religión, sexo, origen nacional, edad, discapacidad, filiación o ideología política; discriminar a cualquier beneficiario de programas que cuenten con apoyo financiero de CCS. El destinatario no debe discriminar en ninguna de las siguientes áreas: decidir quien será admitido o tendrá acceso a cualquier programa o actividad asistido financieramente por CCS, proporcionar oportunidades en el tratamiento de cualquier persona con relación a tal programa o actividad; o tomar decisiones de empleo en la administración de o en conexión con tal programa o actividad. Si cree que ha sido sujeto a discriminación en un programa o actividad con apoyo financiero de CCS, puede presentar una queja dentro de los 180 días a partir de la fecha de la presunta violación, con él destinatario Oficial de Igualdad de Oportunidades (o la persona designada por el destinatario para ese efecto), o bien, con él Director del Departamento Salud y Servicios Humanos, 1301 Young Street, Suite 1169, Dallas, TX 75202, (214) , ó la Oficina del Departamento de Agricultura (USDA), Oficina de Derechos Civiles, Southwest Region, Servicios de Comida y Nutrición, 1100 Commerce Street, Dallas, TX 75242, (214) Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Final por escrito, o hasta transcurridos 90 días (la fecha que ocurra primero) antes de presentar su queja al Centro de Derechos Civiles; ver la dirección arriba. Auxiliary Aids and Services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program. Deaf, hard-of-hearing, or speech impaired customers may contact Relay Texas: (TDD) and 711 (Voice).