CLIENT ID#

STATE:

COUNTY:

DATE:

ELEMENTS OF ELIGIBILITY & PAYMENT DETERMINATION (1)

ANALYSIS OF CASE RECORD (2)

FINDINGS (3)

RESULTS (4)

SECTION I. STATE CHILD CARE PROGRAM FORMS

100 APPLICATION/RE-DETERMINATION FORMS

100 RESULTS

Determine presence, date, and completeness of required eligibility forms, may include (1) signed and dated application form, (2) child care agreement, (3) voucher or certificate, and (4) provider invoice. Specify conditions of dollar error, including (1) form expired, (2) no application form, and (3) no documentation of income and work hours.

0

No Error

1

Client Error

2

Agency Error

SECTION II. PRIORITY GROUP PLACEMENT

200 PRIORITY GROUP PLACEMENT

200 RESULTS

Determine if client meets criteria of State-designated priority groups, e.g., (1) teen parent in high school, (2) TANF recipients in eligible work activities, (3) working parents on TANF, and (4) foster parents etc.

0

No Error

1

Client Error

2

Agency Error

SECTION III. GENERAL PROGRAM REQUIREMENTS

300 QUALIFYING HEAD OF HOUSEHOLD

300 RESULTS

Determine if client meets parent definition (parent means a parent by blood, marriage or adoption and also means a legal guardian, or other person standing in loco parentis), e.g., (1) parent, (2) step-parent, (3) legal guardian, (4) needy caretaker relative, or (5) spouse of same. Child(ren) must be citizen(s).

0

No Error

1

Client Error

2

Agency Error

310 RESIDENCY

310 RESULTS

Determine if client is a resident of the State and for what duration, if client is a resident of the county and for what duration, and whether there is an agreement regarding eligibility among counties.

0

No Error

1

Client Error

2

Agency Error

320 HOUSEHOLD MEMBERS

320 RESULTS

To receive services a child’s parent or parents must be working or attending a job training or educational program.

0

No Error

1

Client Error

2

Agency Error

330 QUALIFYING CHILD

330 RESULTS

Determine if child(ren) is eligible for services, including (1) younger than 13 years, (2) younger than 19 years and physically or mentally incapable of caring for himself or herself, or under court supervision, and (3) in foster care when defined in the State Plan.

0

No Error

1

Client Error

2

Agency Error

340 QUALIFYING CARE

340 RESULTS

Determine hours and type of care authorized. Determine required number of hours of care during authorized schedule.

0

No Error

1

Client Error

2

Agency Error

350 QUALIFYING PROVIDER ARRANGEMENT

350 RESULTS

Determine if services are provided within a center-based child care provider, a group home child care provider, a family child care provider, an in-home child care provider, or other provider of child care services for compensation that Is licensed, regulated, or registered under applicable State or local law. Is informal care included?

0

No Error

1

Client Error

2

Agency Error

360 PROVIDER REQUIREMENTS

360 RESULTS

Determine if regulatory requirements are met. Regulatory requirements means requirements necessary for a provider to legally provide child care services in a State or locality, including registration requirements established under State, local, or tribal law.

0

No Error

1

Client Error

2

Agency Error

SECTION IV. INCOME AND PAYMENTS

400 INCOME

400 RESULTS

Describe income documentation verification for each member of the household. Specify time period and all income to be considered, e.g., based on 4 weeks prior to application: Collect the following data: (1) head of household employment income, (2) spouse employment income, (3) any changes in income reported, (4) income during job training for parent/caregiver, (5) child support, if included as part of income, (6) Food Stamps, if included as part of income, and (7) loss of income during eligibility period.

0

No Error

1

Client Error

2

Agency Error

410 INCOME ELIGIBILITY

410 RESULTS

Determine if household income meets State requirements (e.g., family gross income must be within 50% of State’s median income).

0

No Error

1

Client Error

2

Agency Error

420 PAYMENTS, GENERAL

420 RESULTS

Determine if payments were made. A sliding fee scale based on income and the size of the family and may be based on other factors as appropriate.

0

No Error

1

Client Error

2

Agency Error

430 PAYMENTS/COMPUTATIONS

430 RESULTS

Determine difference in dollar amount of child care benefits authorized versus the amount that should have been authorized—indicate if it is an overpayment or underpayment.

0

No Error

1

Client Error

2

Agency Error