SR 11-17 Dated 05/11

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases new Form NHEP200, Child Care Costs Worksheet, and its associated instructions.

POLICY

New Form NHEP200, Child Care Costs Worksheet, was created:

·   to help inform New Hampshire Employment Program (NHEP) participants about their financial responsibilities while receiving child care assistance; and

·   to be used as a tool for estimating the NHEP participant’s financial obligations to their child care providers.

New Form NHEP200 may be provided to NHEP participants receiving or applying for child care assistance when requested by the NHEP participant. Providing NHEP participants with Form NHEP200, along with CDB Form 2625, NH Child Care Scholarship: Child Care Assistance, is useful but not required.

This new form is used solely by the NHEP participant applying for NH Child Care (NHCC) Scholarship, and only if the applicant would like to use it. NHEP staff are not required to provide this new form to every NHEP participant/child care assistance applicant, nor will every child care assistance applicant necessarily need this new form. If an applicant for child care requests help in obtaining information regarding their child care related financial obligations, staff may assist the applicant by providing this form.

DESCRIPTION OF NEW FORM NHEP200

New Form NHEP 200, Child Care Costs Worksheet, is a one-sided, 1-page informational form and worksheet. The form is used to advise NHEP participants about their financial responsibilities while receiving child care assistance and as a tool for them to estimate their out-of-pocket financial obligations to their child care providers.

Form NHEP200 provides some basic questions for the NHEP participant applying for child care assistance to ask their child care provider. It is hoped that by using this form, the NHCC Scholarship applicant can eliminate misunderstandings regarding their financial responsibilities and obligations. Additionally, Form NHEP200 contains a worksheet section where the NHEP participant/NHCC Scholarship applicant can estimate how much they will owe their child care provider in out-of-pocket expenses.

Because Form NHEP200 is an informational document used solely as a tool by the NHEP applicant who is applying for child care assistance, and only if the applicant wants to use it, it is not retained in the case record. Instructions for this form were created accordingly.

NHEP OFFICE PROCEDURES AND IMPLEMENTATION

Current NHEP training and orientation procedures remain unchanged. Form NHEP200, Child Care Costs Worksheet, may be provided to NHEP participants receiving or applying for child care assistance along with CDB Form 2625, Child Care Scholarship: Child Care Assistance. Providing the informational worksheet, Form NHEP200, to NHEP participants applying for child care assistance is useful but not a required action.

CLIENT NOTIFICATION

No special client notification is planned or needed.

TRAINING

No special training is planned or needed.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and this SR has been posted to the On-line manual.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective June 27, 2011.

DFA/KD:s