CONNECTICUT BIRTH TO THREE SYSTEM

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					                                     FAMILY COST PARTICIPATION FORM



Child’s Name:                                                                              Case #


Schedule of Cost Participation – Conn. General Statute 17a-248(g) requires a schedule of fees to be
established based on a sliding scale.
I understand my fee will be based on:
(1) the family size reported below (Note: “Family” is defined as a group of two or more persons related by
birth, marriage, or adoption who live together), and (2) my family’s federal adjusted gross income as
reported on your most recent state or federal tax return, and (3) the information on our health insurance that
I have provided on form 1-3 and, if applicable, 1-3a
Family Size:  3 or fewer         4  5  6 or more
                                                        Monthly fees if agreeing to have       Monthly fees if declining to have
                                                        insurance billed or if uninsured              insurance billed
                                                                 or uninsured                            or uninsured
    Family Adjusted                                              Family Size                           Family Size
    Gross Income                                        2-3       4      5          6+          2-3      4      5         6+
     Less than $45,000
     $ 45,000-$55,000                                  24        16       8         8          48       32       16      16

     $ 55,001-$65,000                                  32        24      16         8          64       48       32      16

     $ 65,001-$75,000                                  40        32      24       16           80       64       48      32

     $ 75,001-$85,000                                  56        48      40       32          112       96       80      64

     $ 85,001-$95,000                              104           96      88       80          208      192     176      160

     $ 95,001-$105,000                             120         112      104       96          240      224     208      192

     $105,001-$125,000                             152         144      136      128          304      288     272      256

     $125,001-$150,000                             192         184      176      168          384      368     352      336

     $150,001-$175,000                             232         224      216      208          464      448     432      416

     Over $175,001                                 272         264      256      248          544      528     512      496

     I do not wish to disclose our income          272         264      256      248          544      528     512      496

    
    The information provided above represents our family’s annual federal adjusted gross income as shown
     on the most recent State or Federal Income Tax Return. I understand that this figure will be verified
     with the Department of Revenue Services. I also understand that if a significant change in my income
     occurs, I may complete this form again to determine a new monthly contribution rate.
    I understand that I may request an adjustment in my reported family income if I feel that my family has
     extraordinary expenses that should be taken into account. (If this is the case, send an “Application for
     Income Adjustment” to the Birth to Three fiscal office explaining and documenting those extraordinary
     expenses.)
    I understand that adjustments in reported family income are not retroactive and that outstanding
     balances prior to the adjustment are not affected.
    I understand that unpaid balances on monthly financial contributions that equal three months payments
     or more will result in the suspension of all direct early intervention services, other than service
     coordination, assessment, IFSP development and review, and parental rights. I also understand that
     direct services will not resume until the balance is paid in full.

I ________________________________________(print name) acknowledge that I have read and completed
this form accurately. I understand that I will receive an invoice after the first full month of services.

_________________________________                       ____________               SS#________ - ______ - ________
      Parent or Guardian Signature                         Date
Connecticut Birth to Three Form 1-9a (Revised 7/1/12)

				
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