ࡱ> 5@ bjbj22 "&XXE&0W$8\u v$S$<T\,NvRvRvRvRvRvR$TRKWR90"@00RR. . . 0v8N. 0N. R.  /0x @ΝA/3R0S/'X:'X$0$$'X0,.  zRR$$vk $$CHILD DEVELOPMENT AND CARE PARENT RECORD State of Michigan Department of Human Services (DHS)Case Name:  FORMTEXT       Case Number:  FORMTEXT       Date:  FORMTEXT       DHS Office:  FORMTEXT       Specialist:  FORMTEXT       Phone:  FORMTEXT      FORMTEXT       Fax:  FORMTEXT      FORMTEXT       Specialist ID:  FORMTEXT      Why You Are Receiving This Form This is a mandatory form used to complete parent reporting for the Child Development and Care (CDC) program. You are required to complete your Internet or telephone report by the deadline for each pay period. If you miss the deadline, payment to your provider may be delayed, which may result in the loss of care for your child(ren). You are responsible for child care expenses that are not paid by the DHS including expenses incurred while your eligibility is being determined. What You Need to Do: Please be sure to read all these instructions and the instructions on the last page before completing this form. Every two weeks, you are required to report your valid need hours and the hours that your children are in child care. Two options are available to you to complete your reports: The easiest and most convenient option is Internet reporting at:  HYPERLINK "http://www.mi.gov/childcare" www.michigan.gov/childcare If you cannot access a computer you may use telephone reporting at: 1-888-779-2775 (touch-tone) or 1-888-826-1772 (voice) For either option, you will need to know the pay period number, your individual (parent) ID number, and your personal identification number (PIN). For questions about reporting, call 1-866-990-3227. Please make a copy before completing this form. Additional copies may be obtained at  HYPERLINK "http://www.michigan.gov/childcare" www.michigan.gov/childcare or from the DHS office in your area. Based on this report, you may be required to provide documentation (such as check stubs, school schedule, etc.) that supports your entries into the reporting system. Keep your records. An example of how to complete this form is shown below.PARENT ACTUAL ACTIVITY HOURSNeed Reason (Day(SUMOTUWDTHFRSASUMOTUWDTHFRSA1. Employment:7:106:507:057:156:55::7:056:587:157:206:45:2. High School Completion : : : : : ::: : : : : ::3. Approved Activity: : : : : ::: : : : : ::4. Family Preservation : : : : : ::: : : : : ::5. Travel Time: :22 :19 :27 :21 :18:: :25 :27 :19 :18 :17:6. Subtotal (sum of 1-5):7:327:097:327:367:13::7:307:257:347:387:02:7. Row 6 rounded to the nearest half hour*7.57.07.57.57.07.57.57.57.57.0CHILD CARE HOURSChild Name: JamesProvider Name (Day(SUMOTUWDTHFRSASUMOTUWDTHFRSATotal Hours1.Jean Smith :4:154:104:284:16::4:104:054:164:294:45:2. III/Holiday Hours-Provider 1: : : : :4:00 ::: : : : : ::43.: : : : : ::: : : : : ::4. III/Holiday Hours-Provider 2: : : : : ::: : : : : ::5. Subtotal (sum of 1 and 3):4:154:104:284:16::4:104:054:164:294:45:6. Row 5 rounded to the nearest half hour* 4.0 4.0 4.5 4.5 4.0 4.0 4.5 4.5 4.5 39Case NameCase NumberSpecialist REF CaseName   REF CaseNumber   REF WorkerName2  CHILD DEVELOPMENT AND CARE PARENT RECORDAttention: This is a mandatory form that requires completion. You are required to keep this record for 4 years. Do not turn this form in to your DHS specialist or provider.Write down your information here:Individual (Parent) ID:Confirmation Number:Pay Period Begin Date:Pay Period End Date:Pay Period Number:PARENT ACTUAL ACTIVITY HOURSNeed Reason (Day(SUMOTUWDTHFRSASUMOTUWDTHFRSA1. Employment::::::::::::::2. High School Completion ::::::::::::::3. Approved Activity::::::::::::::4. Family Preservation ::::::::::::::5. Travel Time::::::::::::::6. Subtotal (sum of 1-5)::::::::::::::7. Row 6 rounded to the nearest half hour*CHILD CARE HOURSChild Name:Provider Name (Day(SUMOTUWDTHFRSASUMOTUWDTHFRSATotal Hours1.::::::::::::::2. III/Holiday Hours-Provider 1::::::::::::::3.::::::::::::::4. III/Holiday Hours-Provider 2::::::::::::::5. Subtotal (sum of 1 and 3)::::::::::::::6. Row 5 rounded to the nearest half hour*Child Name:Provider Name (Day(SUMOTUWDTHFRSASUMOTUWDTHFRSATotal Hours1.::::::::::::::2. III/Holiday Hours-Provider 1::::::::::::::3.::::::::::::::4. III/Holiday Hours-Provider 2::::::::::::::5. Subtotal (sum of 1 and 3)::::::::::::::6. Row 5 rounded to the nearest half hour** Example: For 6 hours and 40 minutes, enter 6.5 hours. Please read and sign below. I certify that: The information I have reported on the CDC Parent Record is true and accurate to the best of my knowledge based on available information. I understand that if benefits are overpaid for any reason the extra benefits received will have to be repaid. I understand that if intentional misrepresentation caused an overpayment the responsible party including any adult in the program group or the groups authorized representative or provider of goods and services may be prosecuted for fraud.Signature:Date:You may obtain additional copies of this form at  HYPERLINK "http://www.michigan.gov/childcare" www.michigan.gov/childcare or from the DHS office in your area. INSTRUCTIONS CONFIRMATION NUMBER: When you complete your Internet or telephone report you will receive a ten-digit confirmation number. Write the number here for your records. PAY PERIOD BEGIN AND END DATES: Enter begin and end dates for the pay period you are reporting. The table to the right shows when each pay period begins and ends. PAY PERIOD NUMBER: Enter the three-digit number of the pay period. The table to the right shows the number for each two-week pay period. DHS APPROVED ACTIVITY HOURS: For each day, fill in the hours and minutes that you were working or participating in another activity approved by your DHS specialist. Separate rows (1-4) are provided for each activity. Place your travel time in row 5. Travel includes the time it takes to get to and from the child care location and the location of your work (or other approved activity). Include hours and minutes. Add up the rows in each column to get the subtotal. Include hours and minutes. Place this number in row 6. Round the numbers in row 6 to the nearest half hour and place them in row 7. This row contains the numbers you will enter when you report using the Internet or the telephone. CHILD CARE HOURS: For each child, write the name(s) of your child care provider(s) in rows 1and 3. For each day, enter the hours and minutes that provider cared for your child. Do not include hours you did not report in the parent actual activity hours section. Example: If you went shopping for one hour after work before picking up your child from care, do not include that hour here.Pay Period DatesPay Period NumberReporting Deadline*12/21/08 - 01/03/0990101/08/0901/04/09 - 01/17/0990201/22/0901/18/09 - 01/31/0990302/05/0902/01/09 - 02/14/0990402/19/0902/15/09 - 02/28/0990503/05/0903/01/09 - 03/14/0990603/19/0903/15/09 - 03/28/09 90704/02/0903/29/09 - 04/11/0990804/16/0904/12/09 - 04/25/0990904/30/0904/26/09 - 05/09/0991005/14/0905/10/09 - 05/23/0991105/28/0905/24/09 - 06/06/0991206/11/0906/07/09 - 06/20/0991306/25/0906/21/09 - 07/04/0991407/09/0907/05/09 - 07/18/0991507/23/0907/19/09 - 08/01/0991608/06/0908/02/09 - 08/15/0991708/20/0908/16/09 - 08/29/0991809/03/0908/30/09 - 09/12/0991909/17/0909/13/09 - 09/26/0992010/01/0909/27/09 - 10/10/0992110/15/0910/11/09 - 10/24/0992210/29/0910/25/09 - 11/07/0992311/12/0911/08/09 - 11/21/0992411/24/0911/22/09 - 12/05/0992512/10/0912/06/09 - 12/19/0992612/22/09* Reporting deadlines on days before holidays are at 5:00 PM on the indicated date. Otherwise, they are at the end of the day (midnight). For each child on rows 2 and 4, enter the daily hours that were reported to the provider as absent due to illness or for State approved holidays for the two-week period. Sum the ill and holiday hours in the Total Hours column to the far right and enter whole hours only. Use the combined III/Holiday Total when reporting via the telephone or Internet reporting system. Add up rows 1and 3 for each day to get the subtotal child care hours and minutes to place in row 5. Round the subtotals from row 5 to the nearest half hour. Place these rounded totals in row 6. Add across row 6 and fill in the total for the week. If this is a whole number, enter it in the total hours column. Otherwise, enter the next higher whole hour in the total hours column. This weekly total is what you will enter when you report using the Internet or the telephone. HOW TO ROUND TO THE NEAREST HALF HOUR: If remaining minutes are 1 15, drop them. 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