This website or its third-party tools use cookies, which are necessary to its functioning and required to achieve the purposes illustrated in the cookie policy. PARENT INFORMATION Complete the top portion of this form and have your child-care provider complete the remainder. 12-22), MDHHS-5993, American Indian/Alaska Native (AI/AN) Tribal Affiliation Verification - Foster Home (Rev. Use professional pre-built templates to fill in and sign documents online faster. You must complete and send this form to your MDHHS specialist via mail, fax or by using www.michigan.gov/mibridges. Forms Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. A: If you are currently a licensed provider and wish to accept a CDC subsidy-eligible child (ren) into your program, you and the parent will need to complete the DHS-4025, Provider Verification form, selecting you as their provider. A checklist to assist completing the CDC License ExemptProvider Application. This Child Care Verification form is used to notify the Court, as well as the opposing party, that child care is in place for the minor child or children. After reviewing the letter, if you have questions, you may contact 866-990-3227 for assistance. Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF Early learning and development program resources for all children, birth to age eight, especially those in highest need. A: For additional details about the FBI fingerprint process, see the License Exempt ProviderFBI Fingerprint Process. Contractors, Confidentiality 517-241-1806. Child Welfare Medical and Behavioral Health Resources. This is a legal form that was released by the Michigan Circuit Court - a government authority operating within Michigan. Sales, Landlord of Attorney, Personal State(s) Child Abuse and Neglect Registry Check. 235 South Grand Ave., Suite 510 A: You must meet eligibility requirements to become a license exemptprovider in order to receive assistance payments for a child that you care for. Other Out-of-State Entities must complete a Central Registry Clearance Request - DHS-1929 (Word doc)form and send bymail or fax. this verification form is restricted to the purposes cited above. Do you need childcare? These instances are listed in MCL 116 722.115r. multiple forms to execute. Operating Agreements, Employment Forms, Small Read description and preview the template. ^q%m The notice will include the reason for your ineligibility. Agreements, Corporate This is an official form from the State of Michigan. A: The fingerprint background check costs $65.25. There are multiple instances where a person may be found ineligible to be a licensed child care provider. Child Care Verification Form (PDF) , Instructions (PDF) , - For work-related child care expenses Request for a Review (PDF) - To request a review of child support File Access Request Form (PDF) - To access the documents in your Friend of the Court file Parenting Time Violation (PDF) - To report a violation or Parenting Time Denial (S or C-Corps), Articles The Child Development and Care Handbook has been updated as of March 30, 2023. A child care background check is a both a fingerprint-based and name-based check that will cover the following: If a person lived outside of Michigan within the past 5 years, the following checks will also be conducted for each state or country the person has lived in during the past 5 years: If a person lived in another country and is unable to obtain the equivalent background check components, the person must sign a self-certifying statement that he or she is not ineligible to receive a license, to be an adult member of the household, or to be a child care staff member. National Sex Offender Public Website (NSOPW). The web Browser you are currently using is unsupported, and some features of this site may not work as intended. The pay period number (see Payment Schedule). CDC specific instructional videos include: Theseinstructional videosprovide helpful information and resources to support providers with billing and payments. For currently enrolled license exempt - unrelated providers who have not completed the fingerprint background check. If you have someone such as an adult household member who is unable to leave the home, please contact your licensing consultant to request someone to come into the home to fingerprint them. 1-866-990-3227, Preventing Suspension and Expulsion in Early Education, Great Start Collaboratives and Parent Coalitions, https://dev.michigan.local/som/json?sc_device=json. Forms and applications listed here are only a portion of those available. Agreements, Corporate Minutes, Corporate If you are a licensed child care provider, or want to become one, these resources can help: Get licensed as a Family or Group Child Care Home, Family and Group Home Child Care Home Application Renewal Information, Child Care Center Application Renewal Information. Select a subscription plan that really works for your budget. Information on assistance with home repairs, heat and utility bills, relocation, home ownership, burials, home energy, and eligibility requirements. HVnF}W({0`I@R (&QS;%Ejy!w3{%BboQlKgj 4Q\.]6QkW\]"\`>jx(+&K z% "'Qkx3:+\M)h@$l[3;xMh?&)L7{8<<8-xFS$VV;Cc]TU1:Iq`Vgow !'5On)$KI KZ(DI1jL-URn7W$Pz+. Information on the Family Independence Program, State Disability Assistance, SSI, Refugee, and other cash assistance. Note the star ratings for each facility. Liens, Real 8-18), CWL-0120A, North American Indian Tribal Affiliation Verification, Court Operated Facility Rules Review Worksheets, CWL-4603, Incident Accident Illness Death or Fire Report, CWL-4614, Criminal History Record Information Challenge or Correction Form, MDHHS-5612, Verification of Tribal Foster Home Safety Requirements, DHS-120, American Indian/Alaska Native (AI/AN) Court Hearing Notification, DHS-120-A, ICWA/MIFPA Multiple Document Mailing Cover Sheet, DHS-120-B, Transfer To Tribal Agency/Court, DHS-120-C, American Indian/Alaska Native Child Welfare Cultural Plan, DHS-121-A, American Indian/Alaska Native Descendant Child Welfare Case Notification, Indian Child Welfare Act Performance Checklist, DHS-382, Native American Outreach Services Referral, DHS-383, Native American Outreach Services Contract Log (Rev. Who is required to have a Child Care Background Check? !YXNK'^A8i R"3&26HD1l2kY2Nt7yHl1H4gDl--\96F mej% (:0+7,(jZt4MH~:81'*:Y 58A@%h}izFiCkk=rh6! Programs for healthy children & families, including immunization, lead poisoning prevention, prenatal smoking cessation, and many others. Appeals or requests for correction to a MSP PSOR placement must be addressed with Michigan State Police. My Account, Forms in As soon as you are confident the sample is what you need, click on Buy Now. The PDF versions are not fillable and are intended for printing. MI Kids Matter is a resource from the Michigan Department of Education Office of Great Start. Take your completed Motion to Review Child Support to the Muskegon County Circuit Court Records, located on the sixth floor of the Michael E. Kobza Hall of Justice, 990 Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF Form 1310 Bank Statement Verification - Michigan, Form 1309 Account Receivable Verification - Michigan, Form H1135 Child Care Expense Verification - Texas (English/Spanish), Form H1135 Child Care Expense Verification - Texas, Form CC59 Child Care Center - Child Care Associate Reference - Alaska, Form 1863 Child Care Provider Verification - New Hampshire, Child Care Verification of Reopening - Maryland. Information and Resources- If you are a licensed child care provider, or wish to become one, we encourage you to take advantage of our information and resources to help you provide quality care. A: To be paid, you must submit billing information to the Department using I-Billing (Internet Billing). Will, All Michigan has an innovative and comprehensive system of assessments to measure student achievement in learning our state content standards. Low-income Households Water Assistance Program (LIHWAP). Beginning February 1, 2023, Quality Levels will replace Star Ratings. Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form. Solicitud de Proveedor Exento de Licencia para Desarrollo y Cuidado Infantil (CDC). FOC 39e (3/09) CHILD-CARE VERIFICATION. Verificacion de Antecedentes de Cuidado Infantil del Estado de Michigan Consentimiento y Revalacion. Trust, Living for Deed, Promissory Bridge Card Participation Information on Electronic Benefits for clients and businesses, lists of participating retailers and ATMs, and QUEST. The Word documents are fillable and are intended for electronic completion. %%EOF A variety of reports & statistics for programs and services. Information on Adult Protective Services, Independent Living Services, Adult Community Placement Services, and HIV/AIDS Support Services. See the CDC Handbookfor more Level 2 training requirements and information. A: If you are currently a licensed provider and wish to accept a CDC subsidy-eligible child(ren) into your program, you and the parent will need to complete the DHS-4025, Provider Verification form, selecting you as their provider. Save: This form is part of a package. P.O. Apply to become a license exempt related or unrelated child care provider: Apply to become a license-exempt provider. Apply to become a license exempt related or unrelated child care provider. Tenant, More Real All staff that have contact with children will also have to complete a comprehensive background check. Tags: Child Care Verification, FD-FOC 4036, Michigan Local County, Wayne STATE OF MICHIGAN COUNTY OF WAYNE THIRD JUDICIAL CIRCUIT COURT FAMILY DIVISION CASE NO. Resources for educator certification, recognition programs, evaluation, and workforce research. Information forreceiving payments electronically through Electronic Funds Transfer (EFT). The Michigan Department of Health and Human Services' (MDHHS) Division of Environmental Health (DEH) uses the best available science to reduce, eliminate, or prevent harm from environmental, chemical, and physical hazards. Living Theft, Personal Michigan Department of Education Adult Member of Household (Family and Group), Volunteers with Unsupervised Access to children in care (Family, Group and Center), An individual who has unsupervised access to children who are cared for or supervised by a family child care home, group child care home, or child care center. %PDF-1.6 % CDC limits on provider billing per pay period. How much does a Child Care Background Check Cost? Other documents you will need: Your selected provider will need to fill out a provider verification form before they can collect payment: https://www.michigan.gov/documents/dhs/DHS-4025_297108_7.pdf If you don't already have one, you can find a provider on the web at http://greatstarttoquality.org/. Center, Small Estates, Forms dhs child care forms michigan dhs-4025 (rev. Save the modified document on your device, export it to the cloud, print it . Details of CDC payment, including block payments, hourly payments, and other factors affecting payment. Prevention of diseases & conditions such as heart disease, cancer, diabetes and many others. Contact: Is Michigan a National Crime Prevention and Privacy Compact State? Templates, Name Child care background checks are completed on the following individuals: An adult member of the household shall not move into the home of a licensed child care provider until they have completed a child care background check and been found eligible by the department. Visit your local MDHHS Officefor forms or applications not available online. This is an official form from the State of Michigan. To begin, complete a CDC License Exempt ProviderApplication, which can also be found below or call 1-866-990-3227. Begin a Michigan criminal history check by visiting The Michigan State Police (MSP)Internet Criminal History Access Tool (ICHAT) website. Fire Safety Provisions - BCAL-0722, Child Care Center Compliance Record, Part 4. This Child Care Verification form is used to notify the Court, as well as the opposing party, that child care is in place for the minor child or children. You may find approved Level 2 trainings at MiRegistry Statewide Training Calendar. Sibling (only if the provider and the child do not live together). If you have questions about your fingerprint denial you may contact LARA for assistance at 844-765-2247. You must meet requirements and apply to become a license exemptprovider in order to receive assistance payments for a child that you care for. If you do not have Reader installed on your computer, it is available free of charge from Adobe's web site. Manualde Desarrolloy Cuidado Infantil (CDC). Information about the health care programs available through Medicaid and how to qualify. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. Summer 2022 Child Care Stabilization Grants:To go directly to information about the Summer 2022 grants, click the following link: Summer 2022 Child Care Stabilization Grants. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. Required for new building/renovations only. (MUST BE PROVIDED) CHILD CARE VERIFICATION FORM (SSN IF CASE NO. Resources for supporting special education in Michigan. This is an official form from the State of Michigan. Information on American Indian Services, Employment and Training. The applicant or the licensee pays for the background check. Learn more about the MDE office responsible for providing leadership in curriculum and instruction that provides students with greater choices to prepare for success. Family and Group Home Increased Capacity and Ratio Request - Word Version, Family and Group Home Increased Capacity and Ratio Request PDF Version, Waiver for Decreasing Capacity Fillable Word Version, Waiver for Decreasing Capacity PDF Version, Request of Child Care Forms CCL-2021 PDF, Request of Child Care Forms CCL-2021 Word, Child Care Licensing Information Request - CCL 001 -PDF, Child Care Licensing Information Request - CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - PDF, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word, Background Check and Fingerprinting Information, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - PDF, Notification of Changes in Status-Family and Group Child Care Home - CCL-1485 - Word, Medical Clearance Request - CCL-3704 - PDF, Medical Clearance Request - CCL-3704 - Word, Child Information Record - CCL-3731 - PDF, Child Information Record - CCL-3731 - Word, Child Information Record - CCL 3731-AR (Arabic), Documento de Informacin del Nio Estado de Michigan - CCL-3731-SP, Zoning Approval for Group Child Care Homes - CCL-3748 - PDF, Zoning Approval for Group Child Care Homes - CCL-3748 - Word, Declaracin/Recibo de Nios en Cuidado - CCL-3900-SP, Child in Care Statement/Receipt - CCL-3900 - PDF, Child in Care Statement/Receipt - CCL-3900 - Word, Training Record Family/Group Child Care Homes - CCL-4590 PDF, Training Record Family/Group Child Care Homes - CCL-4590 - Word, Assistant Caregiver Certifications - CCL-4595 - PDF, Assistant Caregiver Certifications - CCL-4595 - Word, Home Fire and Tornado Drill Record - CCL-4593 - PDF, Home Fire and Tornado Drill Record - CCL - 4593 - Word, Licensing Notebook Summary Sheet - CCL-5052 - PDF, Licensing Notebook Summary Sheet - CCL-5052 - Word, Request for Modification of the Terms of the License - CCL-5054 - PDF, Request for Modification of the Terms of the License - CCL-5054 - Word, Variance Request Early Childhood Program Director Fillable Word Version, Variance Request Early Childhood Program Director PDF Version, Variance Request School-Age Program Director Fillable Word Version, Variance Request School-Age Program Director PDF Version, Variance Request Lead Caregiver Fillable Word Version, Variance Request Lead Caregiver PDF Version, Child Care Licensing Information Request - BCHS-CCL 001 - PDF, Child Care Licensing Information Request - BCHS-CCL 001 - Word, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - PDF, Medication Permission and Instructions for Child Care Homes/Child Care Centers - CCL-1243 - Word, Permiso e Instrucciones Para la Medicacin Para Casas de Cuidado/Guarderias - CCL-1243-SP - Word. Proceso de Apelacin por Negacin de Huellas Dactilares del FBI. CHILD DEVELOPMENT AND CARE PROVIDER VERIFICATION INSTRUCTIONS: Due Date: Complete the form below. Legal Disclaimer: The information provided on TemplateRoller.com is for general and educational purposes only and is not a substitute for professional advice. Form FOC39E Child-Care Verification - Michigan Form FOC39E Child-Care Verification - Michigan Preview Fill PDF Online Download PDF What Is Form FOC39E?
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