noticeofactionformcd7617-childdevelopmentca-1.Notice.docVIP

1. Notice of Action Complete Either 1.A. or 1.B. 1.A. Application for Services Services Approved to Begin: Date Services Denied If appealed, appeal is due by: Date Note: Appeal Instructions are on reverse side. 1.B. Recipient of Services Change in Service Termination of Service Termination of Service for Delinquent Fees Effective Date of Action: If appealed, date appeal is due by: 2. Distribution of Notice Date Notice Given or Mailed: Notice Given to Parent/Caretaker Recipients Initials: Notice Mailed: First Class Other: ________________________ Tracking No. 3. Parent/Caretaker Information Parent/Caretaker A Address Parent/Caretaker B City Zip Telephone 4. Approved Child Care Services Complete all information for each child approved for services. Name s of Child ren Receiving Services Program Code Enter Approved Hours of Enrollment Sun. Mon. Tues. Wed. Thurs. Fri. Sat. School Vacation School Vacation School Vacation School Vacation Monthly Family Fee Part-time $ Full-time $ 5. Basis for Family Eligibility for Services 6. Basis for Family Need for Services Recipient of Child Protective Services Current Aid Recipient Child ren Identified as At Risk of Being Abused, Neglected, or Exploited Income Eligible Reference Family Fee Schedule or Income Ceiling for Admission to State Preschool Programs. Homeless This section does not apply to State Preschool Programs [CSPP] Recipient of Child Protective Services Child ren Identified as At Risk of Being Abused, Neglected, or Exploited Seeking Permanent Housing Engaged in Vocational Training/Education Employed or Seeking Employment Incapacitated Parent s 7. Reason for Action: State the specific reason s services were denied, changed, or terminated. Agency Name Name/Title of Agency Representative Signature of Agency Representative The agency must complete the information on the reverse side before the Notice of Action is issued. Appeal Information: If you do not agree wi