CTS! Child Care Assistance Program (2019)

CTS! Child Care Assistance Program

Provider Application

Your Name Your Social Security Number Your Telephone Number

Your Street Address Your Mailing Address

Please indicate the type of care you provide:

o In-Home Care (in your home) o Day Care Center (more than 12 children)

o Inthe Child’s Home o Group Home (no more than 12 children)

o Relative Care (you are related to the child)

Are you currently registered or certified with the Child Care Division? Yes [] No []

If yes, please write your Provider Number here:

And, attach a copy of your State Childcare Certification Sheet

Childcare Providers must complete two online trainings, Introduction to Child Care Health and Safety (ICCHS)

and Recognizing and Reporting Child Abuse and Neglect (RRCAN). You can access these trainings at the

Oregon Early Learning Division website https://oregonearlylearning.com . Select Providers and Educators,

Self Study Trainings. After completing the courses you must print out and mail in a copy of the certificates to

verify you completed the trainings.

If you provide care in your home, list you and all adults age eighteen (18) and older who live in your home. If

you provide care in the child(ren)’s home, list yourself only. Person’s named below must enroll in the Office of

Child Care’s Central Background Registry. Under Oregon law, persons convicted of child abuse and certain

other crimes may not be listed or live with a listed provider (OAR 412-10-565).

Name of Adults (List yourself first) Male Female Birth date

Yes

No

Do you provide care to more than three (3) children at any one time who are from more than [_] []

one family? (For Program Use: State Registration required?)

Give the following information for the child(ren) you will be caring for:

Child’s Name Hourly Rate | Related to You? | If related, How?

Yes No

OOOO

OOOO

Give the following information for any other child(ren) you currently provide care for:

Child’s Name Days and Hours in Care

Provider Agreement

CTSI Child Care Assistance Program requires that you agree to certain condition before you get your

payments. The requirements are as follows:

If required, | will participate in all scheduled provider training;

| will keep accurate records and submit payment claims on a timely basis;

| understand claims must be submitted within ninety (90) days from the date child care was provided or

they will not be paid;

I will allow CTSI Child Care Assistance Program to review my records upon request;

| will give parents information about immunizations;

| will take steps to prevent the spread of infectious disease;

| will let parents of the child(ren) in my care have access to their child(ren) at all times;

| will inform CTSI Child Care Assistance of any arrests or convictions of myself or any person living with

me;

1 will inform CTSI Child Care Assistance of name and address changes, or changes of who lives with me;

| will supervise the child(ren) in my care at all times;

| will not use physical punishment or threats to manage any child’s behavior; and

1 will not indulge in or be under the influence of any alcohol or drugs while providing child care.

| understand that | am employed by the parent whom | provide childcare for, and | am not an employee of

the Confederated Tribes of Siletz Indians of Oregon or the CTSI Childcare Assistance Program.

| understand that if care is provided in the child’s home that the parent is responsible for meeting any

minimum wage requirements.

| understand that | must enroll in the Central Background Registry and complete online trainings for

Health and safety.

& € FEEEE FEEEE EEE

| agree to the above requirements. By signing this form, | state the information | have given is true and

complete. | understand caregivers must be age eighteen (18) and older. | understand that if | do not meet the

provider requirements, my listing may close or be denied.

Provider's Signature Date

Please check “Yes” if we have your permission to refer clients to you: YesL_] No]

Note: The client is responsible to pay for childcare until you are certified. Until certified, you

are not eligible to receive payments from CTSI Childcare Assistance Program.

Tribal Child Care Provider Self Certification Form

Name of Provider: Address:

Date form completed: Maximum number of children in care will be:

Age range: Number of adults caring for children:

ITEM YES | NO | N/A | COMMENTS

1. Child-to-caregiver ratios and group size

meet or exceed state standards.

2. Background checks are completed on

adults working with or around children.

3. Caregivers are participating in

appropriate training.

4, Infants are placed to sleep on their backs.

mn

Infants are always held during bottle

feeding.

6. Written, appropriate policies and

procedures are in place.

7. The child care setting is safe and meets

tribal, state, or local fire and safety

regulations.

8. Approved, properly maintained multipurpose fire extinguishers are readily

available.

9. Operating smoke detectors are in place.

10. There are 2 unblocked exits on each

level.

11. All windows are in good repair. Glass,

screens, and locks are in good condition. >

12. The premises are free of hazardous levels

of lead paint.

13. There is sufficient heating and cooling

within the facility to maintain a .

temperature that will not harm children.

14. The home is clean and free of litter and

rubbish and in good repair.

15. Electrical wall sockets are covered when

children are present.

16. Food storage and preparation area are

clean.

17. Drinking water is accessible to children

while indoors or outdoors.

18. Nutritious meals and snacks are provided.

19. Children do not have access to hazardous

materials, including guns.

20. Garbage is disposed of often enough to

prevent the development of odor, or

attract insects and rodents,

Provider Name: Date:

ITEM YES | NO | N/A | COMMENTS

21. The outside play area is free of litter,

trash, weeds, and other dangerous

objects.

22. Car safety seats and restraint devices are

available and used when transporting

children.

23. Toys and play equipment are clean and

safe.

24. Toys, equipment, and books are age- and

developmentally-appropriate.

25. Outside play area is fenced or adult

supervised.

26. Outside equipment is safe and in good

repair.

27, First aid kit and emergency supplies are

available,

28. Emergency evacuation plan is posted.

29. Children have age-appropriate

immunizations.

| 30. Proper sanitation practices are observed

to reduce the spread of infectious disease.

31. Appropriate hand washing procedures are

used by staff and children.

32. Written policy is in place which identifies

inclusion, exclusion, and dismissal of ill

children.

33. Standard precautions for cleaning up

body fluids are followed.

Please list other adults living in your home.

I certify that all information above is accurate and that I will maintain all tribal child care

requirements when caring for children receiving Tribal reimbursement.

Provider Signature

Date

Form W- 9

(Rev, December 2014)

Department of the Treasury

Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

Give Form to the

requester. Do not

send to the IRS.

1 Name {as shown on your Income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, If different from above

C1 individua/sole proprietor or

single-member LLC

the tax classification of the singie-member owner.

C] Other {see Instructions) >

Print or type

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Oo ¢ Corporation | S Corporation oO Partnership

oO Limited tlability company. Enter the tax classification (C=C corporation, 8=8 corporation, P=partnership) >

Note. For a single-member LLC that Is disregarded, do not check LLC; check the appropriate box in the line above for Exemption from FATCA reporting

4 Exemptions {codes apply only to

certain entities, not individuals; see

Instructions on page 3):

Exempt payee code (If any)

ml Trust/estate.

code (if any)

Applies to accounts maintained outside the US}

5 Address (number, street, and apt. or suite no.)

Requester's name and address (optional)

6 City, state, and ZIP code

See Specific Instructions on page 2.

7 List account number(s) here (optional)

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid

backup withhoiding, For individuals, this is generally your social security number (SSN). However, for a

resident alien, sole proprietor, or disregarded entity, see the Part | instructions on page 3. For other - -

entities, it is your employer identification number (EIN). If you do not have a number, see How to get a

TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for [Employer identification number

guidelines on whose number to enter,

| Soctal security number

or

TEXU Certification

Under penalties of perjury, | certify that:

4. The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to be issued to me); and

2. | am not subject to backup withholding because: {a) | am exempt from backup withholding, or (b) | have not been notified by the Internal Revenue

Service (IRS) that | am subject to backup withholding as a result of a failure to report all interest or dividends, or {c) the [RS has notified me that | am

no longer subject to backup withholding; and

3. lama U.S, eltizen or other U.S. person (defined below); and

4, The FATCA code(s) entered on this form (if any) indicating that | am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding

because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage

interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (RA), and

generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN, See the

instructions on page 3.

Sign Signature of

Here U.S. person >

Date >

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such

as legislation enacted after we refease it} is at www.irs.gov/fw9,

Purpose of Form

An individuat or entity (Form W-9 requester) who is required to file an information

return with the IRS must obtain your correct taxpayer identification number (TIN)

which may be your social security number (SSN), individuat taxpayer identification

number (ITIN), adoption taxpayer Identification number (ATIN), or employer

identification number (EIN}, to report on an information return the amount paid to

you, or other amount reportable on an information return. Examples of information

returns Include, but are not limited to, the following:

* Form 1089-INT {interest earned or paid)

* Form 1089-DiV (dividends, including those from stocks or mutual funds)

* Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

* Form 1099-B {stock or mutual fund sales and certain other transactions by

brokers)

* Form 1099-S (proceeds from real estate transactions)

* Form 1099-K (merchant card and third party network transactions)

* Form 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T

{tuition}

* Form 1099-C (canceled debt)

* Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident allen), to

provide your correct TIN,

ff you do not return Form W-9 to the requester with a TIN, you might be subject

fo backup withhofding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1, Certify that the TIN you are giving is correct (or you are waiting for a number

to be issued),

2. Certify that you are not subject to backup withholding, or

3, Claim exemption from backup withholding if you are a U.S, exempt payee. If

applicable, you are also certifying that as a U.S. person, your allocable share of

any partnership income from a U.S. trade or business is not subject to the

withholding tax on foreign partners‘ share of effectively connected income, and

4, Certify that FATCA code(s) entered on this form (if any) indicating that you are

exempt from the FATCA reporting, is correct. See What is FATCA reporting? on

page 2 for further information.

Cat. No. 10231X

Form W-9 (Rev. 12-2014)

Form W-9 (Rev, 12-2074)

Page 2

Note. If you are a U.S. person and a requester gives you a form other than Form

W-$ to request your TIN, you must use the requester’s form if it is substantially

similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S.

person If you are:

* An individual who is a U.S. citizen or U.S. resident alien;

+ A partnership, corporation, company, or association created or organized in the

United States or under the laws of the United States;

* An estate (other than a foreign estate); or

* A domestic trust (as defined in Regulations sectlon 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in

the United States are generally required to pay a withholding tax under section

1446 on any foreign partners’ share of effectively connected taxable Income from

such business. Further, in certain cases where a Form W-9 has not been received,

the rules under section 1446 require a partnership ta presume that a partner is a

foreign person, and pay the section 1446 withholding tax. Therefore, If you are a

U.S. person that Is a partner In a partnership conducting a trade or business in the

United States, provide Form W-9 to the partnership to establish your U.S. status

and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-8 to the partnership

for purposes of establishing its U.S, status and avoiding withholding on its

allocable share of net income frorn the partnership conducting a trade or business

in the United States:

¢ In the case of a disregarded entity with a U.S. owner, the U.S. owner of the

disregarded entity and not the entity;

¢ In the case of a grantor trust with a U.S, grantor or other U.S. owner, generally,

the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

* In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a

grantor trust} and not the beneficiaries of the trust.

Foreign person. if you are a foreign person or the U.S, branch of a foreign bank

that has elected to be treated as a U.S. person, do not use Form W-S. Instead, use

the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax

on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident allen. Generally, only a nonresident

alien Individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on

certain types of Income. However, most tax treaties contain a provision known as

a “saving clause,” Exceptions specified in the saving clause may permit an

exemption from tax to continue for certain types of income even after the payee

has otherwise become a U.S, resident alien for tax purposes.

Ifyou are a U.S. resident allen who is relying on an exception contained In the

saving clause of a tax treaty to claim an exemption from U.S. tax on certain types

of income, you must attach a statement to Form W-9 that specifies the following

five Items:

1, The treaty country. Generally, this must be the same treaty under which you

claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the Income.

3, The article number (or location) in the tax treaty that contains the saving

clause and its exceptions.

4, The type and amount of income that qualifles for the exemption from tax,

5, Sufficient facts to justify the exemption from tax under the terms of the treaty

articie.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption

from tax for scholarship income received by a Chinese student temporarily present

in the United States. Under U.S. law, this student will become a resident allen for

tax purposes /f his or her stay in the United States exceeds 6 calendar years.

However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated Aprii 30,

1984) allows the provisions of Article 20 to continue to apply even after the

Chinese student becomes a resident afien of the United States. A Chinese student

who qualifies for this exception (under paragraph 2 of the first protocol and Is

relying on this exception to claim an exemption from tax on his or her scholarship

or fellowship Income would attach to Form W-9 a statement that includes the

information described above to support that exemption,

If you are a nonresident allen or a forelgn entity, give the requester the

appropriate completed Form W-8 or Form 8233.

Backup Withholding

What Is backup withholding? Persons making certain payments te you must

under certain conditions withhold and pay to the IRS 28% of such payments. This

is called “backup withholding,” Payments that may be subject to backup

withholding include interest, tax-exempt interest, dividends, broker and barter

exchange transactions, rents, royalties, nonemployee pay, payments made in

settlement of payment card and third party network transactions, and certain

payments from fishing boat operators. Real estate transactions are not subject to

backup withholding.

You will not be subject to backup withholding on payments you receive If you

give the requester your correct TIN, make the proper certifications, and report all

your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester,

2. You do not certify your TIN when required (see the Part II Instructions on page

3 for details),

3. The IRS tells the requester that you furnished an incorrect TIN,

4, The IRS tells you that you are subject to backup withholding because you did

not report all your interest and dividends on your tax return (for reportable interest

and dividends only), or

5. You do not certify to the requester that you are not subject to backup

withholding under 4 above (for reportable interest and dividend accounts opened

after 1983 only}.

Certain payees and payments are exempt from backup withholding. See Exempt

payee code on page 3 and the separate Instructions for the Requester of Form

W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign

financial institution to report all Unitad States account holders that are specified

United States persons, Certain payees are exempt from FATCA reporting, See

Exemption from FATCA reporting code on page 3 and the Instructions for the

Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any persen to whom you claimed to ba

an exempt payee if you are no fonger an exempt payee and anticipate receiving

reportable payments in the future from this person. For example, you may need to

provide updated information if you are a C corporation that elects to be an S

corporation, or if you no longer are tax exempt. In addition, you must furnish a new

Form W-9 If the name or TIN changes for the account; for example, if the grantor

of a grantor trust dies.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are

subject to 4 penalty of $50 for each such fallure unless your failure is due to

reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a

false statement with no reasonabte basis that results in no backup withholding,

you are subject to a $500 penalty.

Criminal penalty for falsifying Information. Willfully falsifying certifications or

affirmations may subject you to criminal penalties including fines and/or

imprisonment.

Misuse of TINs. If the requester discloses or uses TINs In violation of federal law,

the requester may be subject to civil and criminal penalties.

Specific Instructions

Line 1

You must enter one of the following on this line; do not leave this line blank. The

name should match the name on your tax return.

If this Form W-$ is for a joint account, list first, and then circle, the name of the

person or entity whose number you entered in Part | of Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have

changed your last name without informing the Social Security Administration {SSA)

of the name change, enter your first name, the last name as shown on your social

security card, and your new last name.

Note, ITIN applicant: Enter your Individual name as it was entered on your Form

W-7 application, fine 1a. This should also be the same as the name you entered on

the Form 1040/1040A/1040EZ you filed with your application.

b, Sole proprietor or sIngle-member LLC. Enter your individual name as

shown on your 1040/1040A/1040EZ on fine 1. You may enter your business, trade,

or “doing business as” (DBA} name on line 2.

c. Partnership, LLC that is not a single-member LLC, C Corporation, or S

Corporation. Enter the entity's name as shown on the entity's tax return on line 1

and any business, trade, or DBA name on line 2.

d, Other entities, Enter your name as shown on required U.S. federal tax

documents on line 1. This name shouid match the name shown on the charter or

other legal document creating the entity, You may enter any business, trade, or

DBA name on line 2.

9. Disregarded entity. For U.S. federal tax purposes, an entity that is.

disregarded as an entity separate from its owner is treated as a "disregarded

entity.” See Regulations section 301,7701-2(c)(2)(Ill). Enter the owner's name on

line 1. The name of the entity entered on line 1 should never be a disregarded

entity. The name on line 1 should be the name shown on the Income tax return on

which the Income should be reported, For example, if a foreign LLC that Is treated

as a disregarded entity for U.S. federal tax purposes has a single owner that is a

U.S. person, the U.S. owner's name is required to be provided on line 4. If the

direct owner of the entity Is also a disregarded entity, enter the first owner that is.

not disregarded for federal tax purposes. Enter the disregarded entity's name on.

line 2, “Business name/disregarded entity name.” If the owner of the disregarded

entity is a foreign person, the owner must complete an appropriate Form W-8

instead of a Form W-9, This is the case even if the foreign person has a U.S. TIN,

Form W-9 (Rev. 12-2074)

Page 3

Line 2

If you hava a business name, trade name, DBA name, or disregarded entity name,

you may enter it on tine 2.

Line 3

Check the appropriate box in line 3 for the U.S, federal tax classification of the

Person whose name is entered on line 1, Check only one box in line 3.

Limited Llability Company (LLC). If the name on line 1 is an LLC treated as a

partnership for U.S. federal tax purposes, check the "Limited Liability Company”

box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to

be taxed as a corporation, check the “Limited Liability Company” box and in the

space provided enter “C" for C corporation or “S" for S corporation, If itis a

single-member LLC that is a disregarded entity, do not check the "Limited Uability

Company” box; instead check the first box In line 3 “Individual/sole proprietor or

single-member LLC.”

Line 4, Exemptions

\fyou are exempt from backup withholding and/or FATCA reporting, enter in the

appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code,

* Generally, individuals {including sole proprietors) are not exempt from backup

withholding.

* Except as provided below, corporations are exempt from backup withholding

for certain payments, including interest and dividends.

* Corporations are not exempt from backup withholding for payments made in

settlement of payment card or third party network transactions.

* Corporations are not exempt from backup withholding with respect to attorneys’

fees or gross proceeds paid to attorneys, and corporations that provide medical or

health care services are not exempt with respect to payments reportable on Form

1099-MISC.

The following codes identify payees that are exempt from backup withholding.

Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501{a), any IRA, or a

oustodjal account under section 403(b}(7) if the account satisfies the requirements

of section 404 (N(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbla, a U.S. commonwealth or possession, or

any of their political subdivisions or instrumentalities

4--A foreign government or any of its political subdivisions, agencies, or

instrumentaiities

5--A corporation

6--A dealer in securities or commodities required to register in the United

States, the District of Columbia, or a U.S, commonweaith or possession

7A futures commission merchant registered with the Commodity Futures

Trading Commission

8—A real estate Investment trust

9~-An entity registered at all times during the tax year under the investment

Company Act of 1940

40—A common trust fund operated by a bank under section 584(a)

41—A financial institution

42—A middleman known in the investment community as a nominee or

custodian

13—A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup.

withholding. The chart applies to the exempt payees listed above, 4 through 43.

iF the paymentis for... THEN the payment is exempt for...

Interest and dividend payments All exempt payees except

for7

Broker transactions Exempt payees 1 through 4 and 6

through 14 and all G corporations. S

corporations rust not enter an exempt

payee code because they are exempt

only for sales of noncovered securities

acquired prior te 2012.

Barter exchange transactions and

Exempt payees 1 through 4

patronage dividends

Payments over $600 required to be

1 Generally, exempt payees

reported and direct sales over $5,000

1 through 5°

Payments made In settlement of

payment card or third party network

transactions

Exempt payees 1 through 4

1 ee Form 4099-MISC, Miscellaneous Income, and its instructions,

* However, the folowing payments made to a corporation and reportable on Form

1089-MISC are not exempt from backup withholding: medical and health care

payments, attorneys’ fees, gross proceeds paid to an attorney reportable under

section 6045(), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees

that are exempt from reporting under FATCA. These codes apply to persons

submitting this form for accounts malntained outside of the United States by

certain foreign financial institutions, Therefore, if you are only submitting this form

for an account you hold in the United States, you may leave this flald blank.

Consult with the person requesting this form if you are uncertain If the financlat

institution is subject to these requirements, A requester may Indicate that a code is

not required by providing you with a Form W-9 with “Not Applicable” (or any

simitar indication) written or printed on the line for a FATCA. exemption code.

A—An organization exempt from tax under saction 501 (a) or any individual

retirement plan as defined in section 7701 (a)(37)

B—The United States or any of Its agencies or instrumentalities

C—Astate, the District of Columbia, a U.S. commonwealth or possession, or

any of their political subdivisions or instrumentalities

D—A corporation the stock of which Is regularly traded on one or more

established securities markets, as described in Regulations section

4.1472-1(6}(1)),

£—A corporation that Is a member of the same expanded aifiliated group as a

corporation described in Regulations section 1.1472-1 (c(t)

F—A dealer in securities, commodities, or derivative financial instruments

(including notional principal contracts, futures, forwards, and options) that Is

registered as such under the laws of the United States or any state

G—Areal estate investment trust

H—A regulated Investment company as defined in section 851 or an entity

registered at all times during the tax year under the investment Company Act of

1940

|—A common trust fund as defined in section 584(a)

J-—A bank as defined In section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a}(1)

M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note. You may wish to consult with the financial institution requesting this form to

determine whather the FATCA code and/or exempt payee code should be

completed.

Line 5

Enter your address (number, street, and apartment or suite number}. This is where

the requester of this Form W-9 will mail your Information returns,

Line 6

Enter your city, state, and ZIP code,

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not

have and are not eligibie to get an SSN, your TIN is your IRS Individual taxpayer

Identification number {(TIN). Enter it in the social security number box. If you do not

have an (TIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN

or EIN, However, the IRS prefers that you use your SSN.

If you are a singla-member LLC that is disregarded as an entity separate from Its

owner (see Limited Liability Company (LLC) on this page), enter the owner's SSN

{or EIN, If the owner has one). Do not enter the disregarded entity’s EIN. {f the LLC

Is classified as a corporation or partnership, enter the entity's EIN.

Note. See the chart on page 4 for further clarification of name and TIN

combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply

for an SSN, get Form SS-5, Application for a Sociat Security Card, from your tocat

SSA office or get thls form online at www.ssa.gov. You may aiso get this form by

calling 1-800-772-1213, Use Form W-7, Application for IRS Individual Taxpayer

identification Number, to apply for an ITIN, or Form SS-4, Application for Employer

identification Number, to apply for an EIN. You can apply for an EIN online by

accessing the IRS website at www.irs.gov/businesses and clicking on Empioyer

identification Number (EIN) under Starting a Business. You can get Forms W-7 and

SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM

(1-800-829-3676).

If you are asked to complete Form W-8 but do not have a TIN, apply for a TIN

and write “Applied For” in the space for the TIN, sign and date the form, and give It

to the requester, For interest and dividend payments, and certain payments made

with respect to readily tradable instruments, generally you will have 60 days to get

a@ TIN and give it to the requester before you are subject to backup withholding on

payments, The 60-day rule does not apply to other types of payments. You will be

subject to backup withholding on all such payments until you provide your TIN to

the requester.

Note. Entering “Applied For” means that you have already applied for a TIN or that

you intend to apply for one soon,

Caution: A disregarded U.S, entity that has a foreign owner must use the

appropriate Form W-8.

Form W-9 (Rev. 12-2014}

Page 4

Part Il. Certification

To establish to the withholding agent that you are a U.S. person, or resident allen,

sign Form W-9. You may be requested to sign by the withholding agent even If

items 4, 4, or 5 below indicate otherwise.

’ For a joint account, only the person whose TIN Is shown in Part | should sign

(when required), in the case of a disregarded entity, the person Identified on line 4

must sign. Exempt payees, see Exempt payee code eariler.

Signature requirements. Complete the certification as indicated in items 1

through 5 below,

1, Iriterest, dividend, and barter exchange accounts opened before 1984

and broker accounts considered active during 1983. You must give your

correct TIN, but you do not have to sign the certification,

2. Interest, dividend, broker, and barter exchange accounts opened after

1983 and broker accounts considered inactive during 1983. You must sign the

certification or backup withholding will apply. If you ave subject to backup

withholding and you are merely providing your correct TIN to the requester, you

must cross out item 2 in the certification before signing the form.

3. Real estate transactions. You must sign the certification, You may cross out

ttem 2 of the certification.

4, Other payments. You must give your correct TIN, but you do not have to sign

the certification uniess you have been notified that you have previously glven an

Incorrect TIN, “Other payments” include payments made in the course of the

requester's trade or business for rents, royalties, goods (other than bills for

merchandise), medica! and health care services (Including payments to

corporations), payments to a nonemployee for services, payments made In

settlement of payment card and third party network transactions, payments to

sertaln fishing boat crew members and fishermen, and gross proceeds pald to

attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of secured

property, cancellation of debt, qualified tuition program payments (under

section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or

distributions, and pension distributions. You must give your correct TIN, but you

do not have to sign the certification.

What Name and Number To Give the Requester

For this type of account:

Give name and SSN of:

1. Individual

2. Two or more individuals goint

account)

3. Custodian account of a minor

(Uniform Gift to Minors Act}

4. a. The usual revocable savings

trust (grantor Is also trustee)

b. So-called trust account that is

not a legal or valid trust under

state law

5, Sale proprietorship or disregarded

entity owned by an individual

6, Grantor trust filing under Optional

Form 1098 Filing Method 4 (see

Regulations section 1.671-4(b)(2)())

(A)

The individual

The actual owner of the account or,

if combined funds, the first

Individual on the account’

The minor

‘The grantor-trustee"

The actual owner!

The owner"

The grantor*

For this type of account:

Give name and EIN of:

7. Disregarded antity not owned by an.

Individual

8. A valid trust, estate, or pension trust

9. Corporation or LLC electing

corporate status on Form 8832 or

Form 2553

10. Association, club, religious,

charitable, educational, or other taxexempt organization

11. Partnership or multi-member LLC

12. A broker or registered nominee

13, Account with the Department of

Agricultura tn the name of a public

entity (such as a state or local

government, schoo! district, or

prison) that receives agricultural

program payments

44. Grantor trust filing under the Form

1041 Filing Methed or the Optional

Form 1098 Filing Method 2 (see

austen section 1.671-4(6}(2)()

B)

The owner

Legal entity*

The corporation

The organization

The partnership

The broker ornomines

The public entity

The trust

‘List frst and clrcte the name of the person whose number you furnish. If only one personon a

Joint account has an SSN, that person's number must be furnished.

* Glrole the minor’s name and furrish the minor's SSN.

* You must show your individual name and you may also enter your business or DBAname on

the “Business name/disregarded entity” name line. You may use elther your SSN or EIN (if you

have one}, but the IRS encourages you to use your SSN.

“ Ust first and circle the name of the trust, estate, or pension trust, (Do not furnish the TIN of the

personat representative or trustee unless the legal entlty jiself Is not designated Inthe account

title.) Also see Special rules for partnerships on page 2,

*Note, Grantor also must provide a Form W-8 ta trustee of trust,

Note. if no name is circled when more than one name is listed, the number will be

considered to be that of the first name listed.

Secure Your Tax Records from Identity Theft

Identity theft occurs when someone uses your personal information such as your

name, SSN, or other identifying information, without your permission, to commit

fraud or other crimes. An identity thief may use your SSN te get a job or may file a

tax return using your SSN to receive a refund,

Te reduce your risk:

* Protect your SSN,

« Ensure your employer is protecting your SSN, and

* Be careful when choosing a tax preparer.

lf your tax records are affected by Identity theft and you receive a notice from

the IRS, respond right away to the name and phone number printed on the IRS

notice or letter.

If your tax records are not currently affected by Identity theft but you think you

are at risk due to a lost or stolen purse or wallet, questionable credit card activity

or credit report, contact the IRS identity Theft Hotline at 1-800-908-4490 or submit

Form 14039,

For more information, see Publication 4535, Identity Theft Prevention and Victim

Assistance.

Victims of identity theft who are experiencing economic harm or a system

problem, or are seeking help in resolving tax probiems that have not been resolved

through normal channels, may be eligible for Taxpayer Advocate Service (TAS)

assistance, You can reach TAS by calling the TAS toll-free case intake fine at

1-877-777-4778 or TTY/TDD 1-800-829-4059,

Protect yourself from suspicious emails or phishing schemes. Phishing Is the

creation and use of email and websites designed to mimic legitimate business

emalls and websites. The most common act is sending an email to a user falsely

claiming to be an established legitimate enterprise in an attempt to scam the user

into surrendering private Information that will be used for identity theft.

The IRS does not Initlate contacts with taxpayers via emails. Also, the IRS does

not request personal detailed information through email or ask taxpayers for the

PIN numbers, passwords, or similar secret access Information for their credit card,

bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this

message to phishing@irs.gov. You may also report misuse of the IRS name, logo,

or other IRS property to the Treasury inspector General for Tax Administration

(TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal

Trade Commission at; spam@uce. gov or contact them at www.ftc.gov/idtheft or

1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk,

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct

TIN to persons (including federal agencies) who are required to file Information

returns with the IRS to report Interest, dividends, or certain other income paid to

you; mortgage interest you paid; the acquisition or abandonment of secured

Property; the cancellation of debt; or contributions you made to an IRA, Archer

MSA, or HSA. The person collecting this form uses the information on the form to

file information returns with the IRS, reporting the above information. Routine uses

of this information include giving it to the Department of Justice for civil and

criminal litigation and to cities, states, the District of Columbia, and U.S.

commonwealths and possessions for use in administering their laws, The

information also may be disclosed to other countries under a treaty, to federal and

state agencies to enforce civil and criminal laws, or to federal law enforcement and

intelligence agencles to combat terrorism. You must provide your TIN whether or

not you are required to file a tax return. Under section 3406, payers must generally

withhold a percentage of taxable interest, dividend, and certain other payments to

@ payee who does not give a TIN to the payer. Certain penalttes may also apply for

providing false or fraudulent information.

DEPA rr a cy e °

‘ae. Instructions for Application for Enrollment in the

LEARNING Bx

DIVISION

Sexe Office of Child Care’s Central Background Registry

a

fouc ss

&

e

0

The CBR-601 application is used for:

e New enrollment in the Office of Child Care’s Central Background Registry

e Renewing enroliment or reopening an expired Registry enrollment

Requirements:

You must be enrolled in the Office of Child Care’s Central Background Registry if you are 18 years or older and:

e The owner, operator, employee, or volunteer of a program regulated by the Office of Child Care (OCC)

¢ The operator, employee, or volunteer of an Oregon pre-kindergarten or federal Head Start program

« A contractor or employee of a contractor who provides early childhood special education or early

intervention services

e A provider or resident of a registered or certified family child care home

¢ An employee, regular visitor, or individual who has unsupervised contact with children in a regulated

child care facility

e Designated employee or volunteer of a Metro service district

¢ Designated employee or volunteer of the Safe Families For Children Program

An employee or contractor of child care services for the nine federally recognized tribes in Oregon or

administrators of the Tribal Child Care and Development Fund.

NOTE: Your enrollment in the Central Background Registry will be valid for five years unless you are suspended

or removed. The Office of Child Care will mail you a renewal notice approximately four months before your

expiration date.

IMPORTANT: It is your responsibility to notify the Office of Child Care in writing of a change of name, address

or phone number during the five year enrollment period so that we can update your information on file. Please

include your Central Background Registry enrollment number with all correspondence with the Office of Child

Care.

Oregon Department of Education * Early Learning Division * Office of Child Care * www.oregonearlylearniing.com CBR-601 5/7/19.v2

Application Checklist:

Before submitting your application for Enrollment in the Central Background Registry to the Office of Child Care,

complete the following checklist. Please remove the instruction sheet from the application before sending the

form to the Office of Child Care.

Failure to submit a complete application will delay processing

[] Completed and signed form CBR-601 Application for Enrollment in the Office of Child Care’s Central

Background Registry

(Form CO-512 Statement of No Social Security Number if applicable

(1 Written explanation and documentation for response to Section 5: Background Information section of

application (if applicable)

Mail application with original signature to: Office of Child Care

700 Summer St. NE

Salem, OR 97301

Note: For renewal applications, mail your application at least 30 days prior to the enrollment expiration date.

SEE INSTRUCTIONS - “How to complete form CBR-601 Application for Enrollment in the Office of Child Care’s

Central Background Registry”

If you have questions, please call the Office of Child Care Central Office at 503-947-1400 or 1-800-556-6616, or

go to the Office of Child Care website at www.oregonearlylearning.com for more information.

Oregon Department of Education « Early Learning Division * Office of Child Care * www.oregonearlylearniing.com CBR-601 5/7/19.v2

CBR Application for Enrollment in the

Office of Child Care’s Central Background Registry

Section 1: Application Type

[_] NEW- No previous enrollment —_|[_| RENEW-R ["] REOPEN-R

Enrollment to expire within 4 months Enrollment is expired or closed

Section 2: Applicant Information

Last Name First Name Middle Date Of Birth (mm/dd/yy)

Gender [| Male [_] Female SSN (required) Other Names Used (aliases)

Physical Address Mailing Address (if different, include city, state, zip)

City State Zip County of Residence

Email Driver's License Number {Issue State Phone Number

Section 3: Preferred Language NOTE: Not all Office of Child Care materials are available in other languages

[1] English [1 Spanish [] Vietnamese [7] Russian LI chinese LJ other:

Section 4: Employment, Volunteer, or Association

Section 4A:

1) Are you currently employed, volunteering, or associated with a licensed child care home, center, or requesting agency? im yes [_] No

2) Are you currently employed, volunteering, or associated with home or center that is planning on becoming licensed? Cl] ves [] No

(see Section 4 of instruction page for more information on answering this question}

IF “YES”, COMPLETE FACILITY INFORMATION BELOW. IF “NO”, GO TO SECTION 4B

lTenas iNahee Childcare Center Physical Address | 930 W. Buford Avenue, Siletz, OR 97380

Facility Name

|RA836 541-444-2450 | Childcare Worker/Provider

OCC License or ID No Phone No Position or Relationship:

Section 4B:

Are you seeking to be employed, volunteer, or be associated with a licensed child care home, center, or requesting agency? Wi ves LJ] No

{see Section 4 of instruction page for more information on answering this question)

Section 5: Background Information (use additional page if necessary)

1) Have you lived outside of Oregon anytime during the last 5 years before today’s date? Clyves C] no

If yes, complete the Out of State Information form, CBR-602

2) Have you ever been convicted of any crime (misdemeanors or felonies) or committed an offense as a juvenile? ("] ves [7] no

3) Have you been arrested or cited for a crime that has not been resolved, or are you in a diversion program, or committed [_] Yes [_] No

an offense as a juvenile with a final disposition not yet reached?

4) Have you ever been part of a child abuse or child neglect investigation? Ll unsure []ves[-] No

5) Have you ever been the subject of a substantiated finding of adult abuse or neglect? LJ Unsure [] ves] No

6) Have you ever been a foster care provider? [7] ves [[] no

7) If you answered yes to questions 6, did any state agency take any legal action against your (_] yes [[] no

license/certification or did you surrender your license/certification lieu of legal action?

IMPORTANT: If you answered “YES” to questions two, three, four or five please list the specific incident(s) on a separate piece of paper. Describe

the circumstances surrounding the incident(s), including associated legal, court proceedings or results of the investigation, and a description

of any personal changes you have made to address the issues that led to the incident(s). You must indicate the YEAR and the STATE in which

the incident{s} occurred.

Oregon Department of Education © Early Learning Division « Office of Child Care * www.oregonearlylearniing.com CBR-601 5/7/19.v2

If you answered “YES” to questions seven, please list the legal action(s) on a separate piece of paper. Describe the circumstances surrounding

the legal actions(s}, including associated legal, court proceedings or results of the action, and a description of any personal changes you have

made to address the issues that led to the incident(s}. You must indicate the YEAR and the STATE in which the actions (s) occurred.

Continued on back (signature and date required)

FOR OFFICE OF CHILD CARE REPRESENTATIVE TO COMPLETE

Run Date/Initials Pending | Approve Date/Initials cac: C] ¥ CIN Intake Initiats:

Continue Process [) ¥ [1] N Compliance Initials:

CPS: oO Conditional Enroll Date: R

LEDS O Date of Final Approval:

FBI: Cl Deny Date: Withdraw Date:

Section 6: Privacy and Authorization Statement

| have read and understand the instructions for completing this form. | authorize the Office of Child Care to use my Social Security Number as

identification for the background checks, | understand that the Office of Child Care will conduct a criminal history and child welfare background

check on me. | authorize the Office of Child Care to use my fingerprints to obtain information about me from the Federal Bureau of Investigation

and Oregon State Police. | authorize the Office of Child Care to obtain information about me from law enforcement agencies, courts, child

protective service agencies, adult protective services, and foster care agencies in Oregon and other states; and sex offender registries in Oregon

and other jurisdictions | certify that the information | have provided is correct and complete. | understand that if | give false or incomplete

information, | may be denied enrollment in or removed from the Registry.

The Office of Child Care has the authority to collect information pursuant to ORS 329A.030 and ORS 181A.195 to conduct the background

check. The information obtained from the background check is used to make a decision on your enrollment into the Central Background

Registry. The information is kept in accordance with 181A.220, 192.365, 329A.030, Title 28, United States Code, Section 50.12, OAR (166-300-

0015 Schedule Number: 2006-0017). | understand that the information | provide in Sections 4 and 5 of this application may be used to verify

information provided to the Office of Child Care, including information provided as part of other applications.

Results from background checks may be shared between authorized Criminal Justice and Designated Agencies. All other secondary

dissemination of background check information by authorized agencies or personnel is prohibited unless expressly permitted by Oregon

Revised Statute.

| understand that by enrolling in the Office of Child Care’s Central Background Registry | will automatically be enrolled in the Oregon Registry

Online (ORO), a system that manages training and education records for licensing requirements. | understand that my individual contact and

training and education information submitted to ORO may be disclosed to authorized personnel with the Office of Child Care, Oregon Center

for Career Development, Department of Human Services, Teaching Research Institute, Oregon Child Care Resource and Referral Network, 214

info and local child care resource and referral programs.

Applicant’s Signature

Applicant’s Signature Date

Preparer’s Signature (if applicable)

| have read this form to the applicant. The applicant has told me that he/she swears or affirms that all the information provided on this form

is, and any attachments hereto, are true and accurate and agrees with the registry privacy and authorization statement. Furthermore, | have

witnessed the applicant sign, or mark in the signature block of this form.

Preparer’s Signature Date

Preparer Agency Phone Number

Oregon Department of Education « Early Learning Division * Office of Child Care * www.oregonearlylearniing.com CBR-601 5/7/19.v2

HOW TO COMPLETE FORM CBR-601 APPLICATION FOR ENROLLMENT IN THE

OFFICE OF CHILD CARE’S CENTRAL BACKGROUND REGISTRY

Refer to these instructions as you fill out each section. The application will be considered incomplete if any required

information is missing. An incomplete application will be returned to you and may delay processing time.

Section 1: Application Type

Indicate what type of application you are submitting. If you are renewing or reopening your Registry enrollment with

the Office of Child Care, please include your Registry number in the space provided at the top of the application. If

you are unable to obtain your Registry number, you may contact the Office of Child Care Central Office at 503-947-

1400 or 1-800-556-6616 for more information.

Section 2: Application Information

Please include all applicable information in Section 2 of the form, including your Social Security Number (SSN). The

SSN is required for processing the application.

If you do not have an SSN, please include a signed form CO-512 Statement of No Social Security Number with your

application. You may download this form from the Office of Child Care website at www.oregonearlylearning.com, or

call the Office of Child Care Central Office at 503-947-1400 or 1-800-556-6616 to request a form be mailed to you.

Section 3: Language

Select only one language. If you check “other”, please specify the language and/or dialect. However, be advised not

all printed materials are available in other languages.

Section 4: Employed, Volunteering or Associated

Section 4A:

If you are currently employed, volunteering or associated* with a licensed child care home, center or a requesting

agency check “YES” to question number one. If the facility is not a licensed child care home, center or requesting

agency, check “NO” to question number one.

If you are currently employed, volunteering or associated* with a child care home or center that is planning on

becoming licensed, check “YES” to question number two. If the facility is not a licensed child care home, center or

requesting agency, and is not planning on becoming licensed, check “NO” to question number two. If you checked

“YES” to either question, complete the facility information section and skip to Section 5. See position and association

examples below. If you checked “NO” to both questions, go to Section 4B.

Position and Relationship Examples: Owner, Executive Director, Director, Substitute Director, Head Teacher, Teacher,

Substitute Teacher, Aide |, Aide II, Assistant |, Assistant I, Provider, Substitute Provider, Spouse/Partner, Daughter,

Son, Volunteer, Other Adult (e.g. visitor)

Requesting Agency: A childhood care and education program or individual providing care to children which is

regulated by Office of Child Care, an early childhood care and education program, or a program that provides early

childhood special education or early intervention services.

Oregon Department of Education « Early Learning Division * Office of Child Care * www.oregonearlylearniing.com CBR-6014 5/7/19.v2

Requesting Agency Examples: Pre-kindergarten, Parent-as-Teacher, Early intervention or Early Childhood Special

Education Program funded by the Oregon Department of Education.

Section 4B:

If you are seeking to be employed, volunteer, or to be associated* with a licensed child care home, center, a

requesting agency, or a facility that is planning to become licensed, check “YES”. If you are not seeking employment

in one of these facilities check “NO”.

*Note: This includes individuals who are currently working, volunteering, or are a frequent visitor that may have

unsupervised contact with children at a licensed child care home, center, or a requesting agency or are living in the

home.

NOTICE: If you check “NO” to all three questions, the Office of Child Care is not authorized to process your

application and it will be returned to the mailing address you have listed on the application.

Section 5: Background Information

Answer “NO” to question number one if you have resided only in Oregon during the previous 5 years. Permanent

established residency is not affected by out-of-state vacation periods.

if you answer “YES” to question number one you must list all states resided in during the previous 5 years.

Check “YES” to question number two if you have any felony or misdemeanor convictions in your past

Check “YES” to question number two if you have committed an offense as a juvenile

Check “YES” to question number three if you have been arrested or cited for a felony or misdemeanor or committed

an offense as a juvenile AND with a final disposition not yet reached

Check “YES” to question number four if you were a part of (reporting abuse as a mandatory reporter or being a victim

of the investigation does not affect this question}Check “YES” to question number five if you were a part

of...{ reporting abuse as a mandatory reporter or being a victim of the investigation does not affect this question)

Check “ YES” to question number seven if your have been a licensed foster care provider and the state agency took

legal action against license or you surrender your license instead of legal action taken place against your license

If you answer “YES” to questions two, three, four, five, and/or seven please read carefully the section “IMPORTANT”

on the application for further instructions.

All subject individuals will receive instructions on how to complete the Federal Bureau of Investigation fingerprint

check.

Section 6: Privacy and Authorization Statement

An original signature is required in order to process the application.

Oregon Department of Education « Early Learning Division « Office of Child Care * www.oregonearlylearniing.com CBR-601 5/7/19.v2

8: Out of State Information

DIVISION

Please list all of the states you currently reside or previously resided.

Last, First, Mk:

Physical Address:

Resided from:

(mm/yy — mm/yy}

City: State:

Zip Code: County:

Resided from:

Last, First, Ml: {mm/yy — mm/yy)

Physical Address: _ )

City: State:

Zip Code: County:

Resided from:

Last, First, Ml: {mm/yy —mm/yy)

Physical Address: _ )

City: State:

Zip Code: County:

Resided from:

Last, First, MI: (mm/yy — mm/yy)

Physical Address: _ )

City: State:

Zip Code: County:

Oregon Department of Education Early Learning Division * Office of Child Care « www.oregonearlylearning.com

CBR-602 5/7/19