Article Guide
The DHS 4025 form serves a vital role in Michigan's Child Development and Care (CDC) program, providing necessary documentation for families seeking financial assistance with child care expenses. It is essential for both parents and child care providers to complete this form accurately and on time. Key elements include the requirement to gather basic information, such as the case name and number, as well as detailed provider and child information. Both the parent and the provider must be aware that completing this form is not just a formality; it is mandatory, and failing to do so can lead to the suspension of subsidy payments. This form also includes a parent agreement section where caregivers acknowledge their responsibilities and the implications of choosing an unlicensed provider. By signing, both parties commit to adhering to the program's rules. Moreover, the Michigan Department of Health and Human Services (MDHHS) ensures that the process is non-discriminatory and straightforward, reflecting its commitment to accessibility for all families in need of assistance. Understanding the completion instructions and the consequences of noncompliance is critical for receiving timely child care benefits.
Form Sample
Case Name:
Case Number:
Date:
MDHHS Office:
Specialist:
Phone:
Fax:
Specialist ID:
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
AUTHORITY: Public Act 280 of 1939.
COMPLETION: Mandatory.
CONSEQUENCE FOR NONCOMPLETION: Child care subsidy payments will not be authorized.
CHILD DEVELOPMENT AND CARE (CDC) PROVIDER VERIFICATION
PURPOSE: You have received this form because you have applied for assistance with child care expenses through the Child Development and Care (CDC) program or have changed your CDC provider. You must complete and send this form by the Due Date to your MDHHS Specialist via mail, fax or by using www.michigan.gov/mibridges. You will not receive CDC benefits until you complete this form and receive your approval notice.
INSTRUCTIONS:
Work with your chosen provider to complete all the information included on Page 1 and Page 2 of this form. Both you and your provider must read the agreement and sign and date Page 2.
Return the form to your MDHHS specialist by the Due Date. If the form is not received by the Due Date, you or your provider will not receive CDC payments for child care expenses.
You and your provider will receive a notice from the CDC program if care is approved.
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Due Date: |
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SECTION 1: PROVIDER INFORMATION (To be completed by the provider) |
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Provider or Child Care Center Director Name |
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Child Care Center Name |
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Provider CDC ID # |
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Address (Number and Street) |
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City |
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State |
Zip Code |
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MI |
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County |
Telephone Number |
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- - |
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Do you receive any other payments (such as from an employer, child support, or other assistance program) for caring for the children listed in Section 2?
NO |
YES If YES, for what children (list children)? |
If YES, whom do you receive payment from? |
Where do you usually care for the children listed in Section 2? (Check one)
Note: If you are an unlicensed provider who is not related to the children in Section 2, you must provide care in the children’s home.
Child Care Center |
Group Child Care Home |
Family Child Care Home |
Home Where The Child Lives |
My Home |
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SECTION 2: CHILD INFORMATION (To be completed by the provider):
(Please list all children in the family in your care. Attach a list of additional children to this form if needed.)
Child’s Name |
Date of |
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Date Care |
Is the child related to you? |
If YES, how are you related? |
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Birth |
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Began |
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1. |
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NO |
YES |
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2. |
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NO |
YES |
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3. |
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NO |
YES |
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4. |
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NO |
YES |
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1 |
For additional assistance, contact your MDHHS specialist. |
Case Name
Case Number
Specialist
SECTION 3: PARENT/SUBSTITUTE PARENT AGREEMENT (To be completed by the parent) By signing, you agree to the following:
1.I understand that if I choose an unlicensed provider:
a.I am responsible for any child care expenses for the time my child is in care before my provider completes the Great Start to Quality Orientation training.
b.CDC payments will be issued to me and I am responsible for paying my provider.
c.I am responsible for reporting child care payments to the IRS and issuing my provider a Form
2.I certify that my child or children are or will be in care with this provider as of the “date care began” listed in Section 2.
3.I understand that my child care agreement is between myself and my provider.
4.I understand that the Department may request information from me in order to verify my provider’s billing information.
5.I understand and agree that if an overpayment is made to my provider for any reason, my provider must repay the extra payments. To help repay the money, the Department may reduce any future payments to my provider by up to 20%.
6.I understand that I may be prosecuted for perjury or fraud if I intentionally leave out or give any false information that causes me to receive CDC benefits that I am either not qualified for, or are greater than what I should receive.
7.I understand if I violate any of the program rules, I may be disqualified from the program for six (6) months, 12 months, or a lifetime.
Parent/Substitute Parent Signature |
Date |
SECTION 3: PROVIDER AGREEMENT (To be completed by the provider)
By signing, you agree to the following:
1.I understand if I am an unlicensed provider:
a.I must apply to be a CDC provider by completing the CDC Unlicensed Provider Application. The application can be found at www.michigan.gov/childcare
b.I will not receive CDC payment for any care I provide in the period before I complete the Great Start to Quality Orientation training. More information on the training can be found at www.GreatStarttoQuality.org.
c.CDC payments will be issued to the parent of the child or children in care. The parent is responsible for paying me, reporting my wages to the IRS, and issuing me a Form
d.I will use the CDC Daily Time and Attendance form found at http://www.michigan.gov/childcare.
2.I understand that I am not employed by the State of Michigan or the CDC Program, and that I will not receive unemployment insurance.
3.I will maintain time and attendance records for each child in my care. Each child’s parent/substitute parent must sign the records each day they are in my care. I will retain these records for four (4) years.
4.Parents of the children in care will have unlimited access to their children while in my care.
5.If an audit or investigation finds that I do not keep accurate time and attendance records, I may have to return CDC payments to the Department.
6.If I am overpaid for any reason, I must repay the Department, even if I am overpaid in error. If I am overpaid, the Department may hold up to 20% of any future payments.
7.I am responsible for what happens in the CDC
8.I will immediately contact the CDC Central Reconciliation Unit at
9.I will not bill for hours when the child is in school, to hold a spot for a child, or if the child is not expected to return to my care.
10.I understand that I may be prosecuted for perjury or fraud if I intentionally leave out or give false information that causes the parent/substitute parent to receive CDC benefits they are either not qualified for, or are greater than what they should receive.
11.I understand if I violate any of the program rules, I may be disqualified from the program for six (6) months, 12 months, or a lifetime.
Provider Signature |
Date |
For more information and requirements, see the CDC program handbook at
http://www.michigan.gov/childcare
2 |
For additional assistance, contact your MDHHS specialist. |
Document Specifications
| Fact Name | Description |
|---|---|
| Governing Authority | The form is governed by Public Act 280 of 1939. |
| Completion Status | Completion of the DHS 4025 form is mandatory for eligibility. |
| Consequence for Noncompletion | If not completed, child care subsidy payments will not be authorized. |
| Purpose | This form is used to verify child care providers for those receiving Child Development and Care (CDC) assistance. |
| Submission Methods | The form can be sent via mail, fax, or online through www.michigan.gov/mibridges. |
| Provider Agreement Requirements | Providers must sign the form and maintain accurate records for four years. |
Steps to Filling Out Dhs 4025
After filling out the Dhs 4025 form, send it to the specified MDHHS specialist through mail, fax, or electronically via Michigan's MiBridges platform. Ensure all required sections are completed accurately, as incomplete forms may delay the approval of child care assistance. Keep a copy for personal records.
- Begin with Section 1, where the provider must fill in their details:
- Provider or Child Care Center Director Name
- Child Care Center Name
- Provider CDC ID #
- Address (Number and Street)
- City
- State
- Zip Code
- County
- Telephone Number
- Indicate whether the provider receives any other payments for child care related to the children listed in Section 2. If YES, specify the children and the source of payment.
- For the place of care, choose one option: Child Care Center, Group Child Care Home, Family Child Care Home, Home where the child lives, or My Home.
- Move to Section 2, where the provider lists all children in their care:
- Child’s Name
- Date of Birth
- Date Care Began
- Indicate if the child is related by answering YES or NO, and if YES, describe the relationship.
- Next, Section 3 is dedicated to the agreements to be completed by the parent or substitute parent:
- Read and understand all agreement items before signing.
- Sign and date the agreement. Ensure that all required acknowledgments have been checked.
- Lastly, Section 3, the Provider Agreement, must be filled out by the provider:
- Read and understand all terms listed in the Provider Agreement.
- Provide your signature and date on the appropriate lines.
- Review the entire form for completeness, ensuring all required fields are filled out correctly.
- Submit the completed form to your MDHHS specialist by the Due Date via mail or fax, or through the MiBridges platform.
More About Dhs 4025
What is the Dhs 4025 form?
The Dhs 4025 form is a verification document used by the Michigan Department of Health and Human Services (MDHHS). It is specifically for individuals applying for assistance with child care expenses through the Child Development and Care (CDC) program. This form must be completed and submitted to ensure eligibility for CDC benefits.
Who needs to complete this form?
Both the child care provider and the parent or substitute parent must complete specific sections of the Dhs 4025 form. The provider fills out their information and details about the children in their care, while the parent or substitute parent agrees to the terms outlined on the form.
What happens if I don't complete the form?
If the Dhs 4025 form is not completed and submitted by the due date, child care subsidy payments will not be authorized. As a result, you or your provider will not receive payments for child care expenses until the form is processed and approved.
How do I submit the Dhs 4025 form?
You can submit the completed form by mail, fax, or through the Michigan Bridges website at www.michigan.gov/mibridges. Make sure to send it to your assigned MDHHS specialist.
What information is required on the form?
The form requires detailed information about the child care provider, children being cared for, and an agreement section for both the parent and provider. This includes names, contact information, addresses, and assertions regarding payments and responsibilities.
Is completion of the Dhs 4025 form optional?
No, completing the Dhs 4025 form is mandatory for those wishing to receive CDC benefits. Failure to complete it will affect your eligibility for child care subsidies.
What are the consequences of providing false information on the form?
Providing false information on the Dhs 4025 form may lead to serious consequences, including prosecution for perjury or fraud. Additionally, it could result in penalties such as disqualification from the CDC program for specified periods of time or even permanently.
Can I use a relative as a child care provider?
What if the provider is unlicensed?
If the provider is unlicensed, they must fill out the CDC Unlicensed Provider Application and complete required training before they can receive payments. You, as the parent, will be responsible for any child care expenses incurred before this training is completed.
Where can I find more information about the CDC program?
Additional information about the CDC program, including requirements and guidelines, can be found in the CDC program handbook at http://www.michigan.gov/childcare.
Common mistakes
When completing the DHS 4025 form for the Michigan Child Development and Care (CDC) program, common errors can delay the approval process and result in financial complications. Below is a list of seven frequent mistakes to avoid during this important task.
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Incomplete Information:
Failing to provide complete details in both Section 1 and Section 2 can lead to processing delays. Ensure all fields are filled out accurately, including the provider's name and the children in care.
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Missing Signatures:
Both parents and providers must sign the agreement on Page 2. Missing a signature can render the entire form invalid and result in a delay in benefit approval.
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Misunderstanding Provider Agreements:
It's crucial that both parents and providers fully understand their responsibilities. Unlicensed providers, for example, must complete the Great Start to Quality Orientation training before receiving payments.
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Ignoring the Due Date:
Submitting the form after the specified due date can result in non-approval of CDC payments. It is essential to send the form to the MDHHS specialist on time, either via mail, fax, or online.
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Inaccurate Child Information:
Providing wrong details or omitting children from Section 2 can lead to overpayment or complications in verification. List all children in your care, and ensure their information is correct.
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Failing to Document Income:
If the provider receives payments from other sources, this must be disclosed on the form. Not doing so can lead to issues with compliance and potential legal ramifications.
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Lack of Communication with MDHHS:
If doubts or questions arise while filling out the form, it is wise to reach out to the MDHHS specialist for clarification. Not doing so can result in mistakes that might affect eligibility for CDC benefits.
By avoiding these pitfalls, individuals can significantly enhance their chances of a smooth application process and timely receipt of child care benefits.
Documents used along the form
The DHS 4025 form plays a pivotal role in the process of securing child care assistance through the Child Development and Care (CDC) program in Michigan. However, several other documents are often needed in conjunction with the DHS 4025 to ensure a smooth application and approval process. Here’s a brief overview of those documents:
- CDC Unlicensed Provider Application: This application is essential for unlicensed caregivers who wish to participate in the CDC program. It provides the necessary information about the caregiver and ensures compliance with state regulations before they can receive payments for child care services.
- CDC Daily Time and Attendance Form: Care providers must keep track of the hours children spend in their care using this form. It helps document attendance and ensures that billing is accurate, which is critical for receiving payments through the CDC program.
- Form W-2 or Form 1099 MISC: These tax forms are necessary for reporting income to the IRS. If caregivers are unlicensed, parents must issue these forms to document payments made to them, ensuring compliance with tax obligations.
- Provider Enrollment Agreement: This document outlines the terms of the care arrangement between the provider and the parent. It includes conditions of care, responsibilities, and payment details, fostering clear communication and understanding.
- Child Support Payment Records: If applicable, records of any child support payments received are vital for determining eligibility for CDC benefits. These records help outline any additional income that may affect the assistance amount granted.
Gathering these forms and documents ensures that the process of obtaining child care assistance is efficient and compliant with state regulations. Being well-prepared can help families access the support they need without unnecessary delays.
Similar forms
The DHS 4025 form is quite similar to the Child Care Subsidy Application. Both documents are designed to collect information from parents seeking financial assistance for child care expenses. They require details about the child care provider and the children being cared for. The completion of this application is crucial; without it, parents may not receive any child care subsidies. The requirements emphasize timely submission to support the financial aid process, mirroring the urgency found in the DHS 4025 form.
Another document with a similar purpose is the Child Care Provider Certification Form. This document is used to verify that child care providers meet state requirements and allows parents to ensure their chosen provider is eligible to accept subsidy payments. Like the DHS 4025 form, it emphasizes the importance of accurate and timely information. Both aim to establish a safe and compliant environment for the child’s care, highlighting the regulatory framework that governs child care support.
Equally similar is the Authorization for Child Care Payments. This form serves to approve payments to specific providers for child care services rendered for eligible children. Just as the DHS 4025 assists in formalizing a parent's relationship with a child care provider, this authorization locks in payment details and ensures both parties understand their responsibilities. Timeliness and accuracy are key in both documents to ensure a smooth payment process.
The Parent Provider Agreement shares several features with the DHS 4025 form, as both documents outline the responsibilities of both parents and child care providers. This agreement provides parents with a clear understanding of their obligations, such as payment reporting and care duration. Similarly, the DHS 4025 also specifies what happens if program rules are violated, demonstrating the mutual accountability required for successful participation in the child care program.
The Child Development and Care Provider Application bears resemblance to the DHS 4025 form in that it requires detailed information about child care providers. This form is essential for providers seeking reimbursement for care provided under the CDC program. Like the DHS 4025, it mandates certain guidelines and documentation to verify eligibility and compliance, fostering a systematic approach to accessing child care benefits.
The Attendance Records for Child Care Providers are another comparable document. These records are maintained to track children's attendance and verify the services for which providers are billing. Similarly, the DHS 4025 places a heavy emphasis on maintaining accurate records to prevent improper payment. Both aim for a transparent process that ensures accountability and prevents misuse of funds.
Finally, the Child Development and Care Eligibility Notification reflects the same foundational principles as the DHS 4025 form. Notifications inform parents whether they qualify for assistance and include crucial guidelines to follow. Much like the DHS 4025, which outlines consequences for non-completion, the eligibility notification serves as a reminder for parents to stay informed about their status regarding benefits and compliance with the program’s requirements.
Dos and Don'ts
When filling out the Dhs 4025 form, you want to ensure a smooth process to receive your child care benefits. Here are some tips on what to do and what to avoid.
- Do collaborate with your provider. Make sure both you and your child care provider complete all necessary sections of the form.
- Do send the form by the Due Date. Timeliness is crucial. Mailing or faxing the form after the Due Date could result in a delay or denial of your child care payments.
- Do keep copies of all documents. Retaining a copy of the completed form will help you reference it later if needed.
- Do follow the instructions carefully. Each step is important. Be sure to read and adhere to the guidelines provided within the form thoroughly.
- Don't leave any sections incomplete. Missing information can lead to processing issues, resulting in a denial of benefits.
- Don't wait until the last minute to submit your form. Life can be unpredictable; submitting early helps avoid potential issues.
- Don't sign without understanding. Ensure you read the entire agreement sections before signing to avoid misunderstandings later.
- Don't forget to check for accuracy. Before sending, review all information to confirm that it's correct and complete.
Misconceptions
1. The DHS 4025 form is optional. This form is actually mandatory. Completion is necessary to ensure child care subsidy payments are authorized.
2. Only parents need to fill out the form. In reality, both parents and providers must participate. Providers need to complete their sections, and parents must agree and sign.
3. Submitting the form late has no consequences. If you do not submit the form by the due date, child care subsidy payments will not be authorized. Timely submission is crucial.
4. The form is only for new child care applications. This form is also used when there are changes in your CDC provider. It’s important for both new applications and provider changes.
5. Unlicensed providers do not need to follow any regulations. Unlicensed providers must still apply to be a CDC provider and complete necessary training before they qualify for payments.
6. Parents automatically receive benefits once the form is submitted. Parents will not receive CDC benefits until the form is completed correctly and approved by the MDHHS.
7. I can list any children I want on the form. You must list only the children in your care. Including children that are not under your care can lead to complications.
8. There is no need for documentation of care hours. Providers must maintain accurate time and attendance records for each child to avoid potential issues during audits.
9. The parent is responsible for all payments regardless of circumstances. If overpayments are made, parents and providers share the responsibility of repayment under certain conditions.
10. I can leave out information on the form without consequences. Omitting or falsifying information can lead to prosecution for fraud and disqualification from receiving benefits.
Key takeaways
Filling out the Dhs 4025 form accurately is crucial for securing child care subsidy payments through the Child Development and Care (CDC) program. Here are some key takeaways to consider:
- Mandatory Completion: It is essential to complete the Dhs 4025 form entirely. Failure to do so will result in the denial of child care subsidy payments.
- Collaboration Required: Both the chosen provider and the parent must work together to fill out all sections of the form. Unfinished or unsigned forms will lead to processing delays.
- Due Date Compliance: Sending the completed form to the MDHHS specialist by the specified due date is non-negotiable. Late submissions will jeopardize payment eligibility.
- Provider Information is Key: Ensure that all information pertaining to the child care provider is accurate and complete, including the provider’s name, contact information, and CDC ID number.
- Understanding Responsibilities: Parents must be aware of their financial responsibilities, especially when working with unlicensed providers. They are responsible for any out-of-pocket expenses incurred until the provider is fully trained.
- Legal Implications: Providing false or incomplete information on the form can lead to serious consequences, including prosecution for fraud. Both parents and providers should ensure all details are truthful and accurate.