0002_RFI_Childcare (English) NEMIS Template (121813)

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0002) NOTE: Do not send your completed form to this address.

W. Craig Fugate Governor name

Administrator Governor

Federal Emergency Management Agency State of State

National Processing Service Center

P.O. Box 10055

Hyattsville, MD 20782 - 8055

1-800-621-FEMA (3362)

Fax No.: 1-800-827-8112 Date: 00/00/0000

FEMA Application No. 000000000 Disaster No. 0000

APPLICANTS NAME

STREET ADDRESS

CITY, STATE ZIP

Dear Ms/Mr Applicants Name:

Based on information you provided to FEMA, our records indicate you have a need for child care assistance. FEMA can provide child care assistance as a single payment based on your disaster-related needs. Assistance may be provided for no more than eight weeks of child care. Your assistance may not exceed the maximum amount for child care that is set by your State/Tribe.

To be considered eligible for child care assistance, you must be spending a higher percentage of your household gross income on child care as a result of the disaster. The child who needs care must be no older than age 13; children age 14 up to 18 who have a disability, as defined by Federal law, and who are unable to care for themselves and need child care are also eligible. Additionally, the child care provider you are using after the disaster must be licensed and regulated by your State/Tribal government laws.

To determine your eligibility for child care assistance, we need the following additional information.

1. Pre- and post-disaster household gross income documentation. Provide verifiable documentation that demonstrates the household’s gross income. Verifiable documentation may include pay stubs, income tax forms, Social Security award letters, etc.

Household gross income means income received before taxes for all persons in your household over the age of 18. Gross income may include: 1) Wages and salaries, overtime pay, commissions, fees, tips and bonuses and other compensation for personal services; 2) Interest, dividends and other net income of any kind from real or personal property; 3) Full amount of periodic amounts received from Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits and other similar types of periodic receipts, including lump-sum amount or prospective monthly amounts for the delayed start of a periodic amount; 4) Payments in lieu of earnings, such as unemployment and disability compensation, worker's compensation and severance pay; and 5) Welfare assistance.

2. Child’s Date of Birth. Provide each child’s date of birth for which you are requesting child care assistance.

3. Pre- and post-disaster child care cost documentation. To demonstrate child care costs pre-disaster, you may submit a receipt, a contract/agreement with the child care provider, OR an affidavit if you are not able to provide a contract/agreement or receipt. To demonstrate child care costs post-disaster, you may submit a receipt, a contract/agreement with the child care provider, OR an estimate for a new child care provider. Child care cost documentation must be submitted for each child within your household in which you are requesting child care assistance.

   1. Receipts. A receipt may be submitted for child care costs before and after the disaster. The receipt(s) must include the:

      1. child’s name(s),

      2. child care provider’s name, address, and phone number,

      3. time period covered, and

      4. total costs for that time period.

   2. Child Care Contract or Agreement. Instead of receipts, a contract or agreement with a child care provider may be submitted for child care costs before and after the disaster. The signed contract or agreement, , must include the:

      1. child’s name(s),

      2. child care provider’s name, address, and phone number,

      3. time period covered, and

      4. total costs for that time period.

   3. Affidavit. An affidavit may be submitted for child care costs before the disaster, when receipts or a contract/agreement cannot be located. The affidavit, signed by you and the child care provider, must include the:

      1. child’s name(s),

      2. child care provider’s name, address, and phone number,

      3. time period covered,

      4. total costs for that time period, and

      5. the following signed and dated statement: “I declare under penalty of perjury that the information submitted is true and correct.”

   4. Estimate. An estimate may be submitted if you intend to use a new child care provider after the disaster and you do not yet have a receipt or a contract/agreement. Please submit an estimate of the expected costs from the child care provider you intend to use. The estimate must include the:

      1. Child’s name(s),

      2. child care provider’s name, address, and phone number, and

      3. cost estimate for a certain time period (for example, weekly estimate, monthly cost estimate, etc.).

4. Child age 14 up to 18 who has a Disability. Provide a signed and dated statement from a medical professional for children ages 14 up to18, who have a disability as defined by Federal law and who are unable to care for themselves, stating that your child has a need for child care services due to a disability. Please note: this FEMA program funds child care only and cannot be used for medical assistance.

5. Acknowledgements. Provide a written statement that acknowledges:

   1. The expected length of time you will have a disaster-related need for FEMA child care assistance;

   2. You currently are not receiving assistance from another source that meets all your child care needs. This may include services that are free of charge, assistance from your State/Tribal government to help in paying for your child care costs, compensation from any other government agency, assistance from your employer or any other source that meets your current child care needs;

   3. The information you have submitted is true and correct.

An example of a written statement that can be submitted is: “My household has a disaster-related need for child care assistance. My need for child care assistance will continue for ___ weeks. My household’s child care costs are not being fully met by another source I declare under penalty of perjury that the information submitted is true and correct.”

6. Special Consideration. Please note, for tax purposes, any disaster assistance awarded for child care shall not be treated as taxable income. However, FEMA assistance awarded for child care may not be used to take credit for qualifying child care or dependent care costs under Section 21 of the Internal Revenue Code. For specific questions regarding the preparation of your tax returns, please contact the Internal Revenue Service directly (www.IRS.gov).

Include your FEMA Application Number and Disaster Number on all pages of your documents. Both numbers are printed at the top of the first page of this letter. Keep all originals for your records.

Please provide the information within 21 days. If it is not received, you will not be eligible for child care assistance.

Mail your documents to: Fax your documents to:

FEMA - Applicant Services 1-800-827-8112

National Processing Service Center OR Attention: FEMA - Applicant Services

P.O. Box 10055

Hyattsville, MD 20782-8055

If you have any questions, please call FEMA's Helpline at 1-800-621-FEMA (3362). Disaster assistance applicants, who have a speech disability or hearing loss and use a TTY, call 1-800-462-7585 directly; for those who use 711 or Video Relay Service (VRS), call 1-800-621-3362.

Sincerely,

Individuals and Households Program Officer