CHILD CARE AND PARENT SERVICES (CAPS) by 4zp8tDG

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									                               CHILD CARE AND PARENT SERVICES (CAPS)
                          APPOINTMENT LETTER AND VERIFICATION CHECKLIST


                                                                           Date
Client Name

Client Address                                                             Child Care Service Agent Name

                                                                           Child Care Service Agent Email Address
Apt/Suite #
                                                                           Child Care Service Agent Phone Number
City, State, Zip
                                                                           Child Care Fax Number
Client Email Address

Your application has been received by the CAPS program. To determine your eligibility the checked items must be
received no later than _       ___. Information can be provided by faxed or emailed to the email address and or fax
number listed above or mailed to: __       ___________. If mailing information please do not provide originals.
Failure to provide information before__       _______________ may result in denial or closure of your CAPS
application.

Appointment (If applicable)
You have an appointment on                  at               . Your interview will be conducted by telephone or in person at the
following location.


IMPORTANT: If you cannot keep your appointment, call your caseworker BEFORE your scheduled appointment
date. If you cannot get the requested information and/or need more time, contact your caseworker by phone or mail
by       . Your caseworker may give you more time and may be able to help you get the information you need.


The following is needed to complete your:

   In Person Interview        Phone Interview        In Person Review          Phone Review



                                     Client
      Check Stubs or Statement from employer                                Verification of enrolment in middle or high school or
      for last 4 weeks for:                                                 vocational, technical school.
      Social Security Card (optional)                                       Rates from childcare provider for all children requesting care
      Proof U.S. Citizenship/Alien Status for all children                  Other:
      requesting or receiving care
      Immunization Record for:
      Proof of any unearned income (i.e. Child Support, SSI,
      Social Security, Disability, Unemployment)
      TANF work plan completed by TANF case manager
      Application completed by you                                                       Child Care Provider
      HIPAA Notices of Privacy Practices Signed                             Copy of License/Registration/Exemption
      by you                                                                Letter
      If you have chosen an Informal Provider,                              Copy of Published Rates
      bring him/her with you to your appointment
      with items checked in provider column
      Proof of Residency( i.e. lease, utility bill)                         Social Security Card

      Proof of Identity (i.e Driver’s license, State ID, )                  Picture ID

      Separation Notice from:                                               Other


Form 66A (Rev 12-10)                                     1 Copy – Client                               1 Copy - Case Record

								
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