Form FO-0601A "Application to Determine Eligibility for the Reduced Contribution" - Quebec, Canada

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Application to determine eligibility for the reduced contribution
The letters in a square (example:
A
) appearing on this form refer to the list of documents to be attached.
It is important to check the boxes on the back of this form that correspond to your situation. You must give
the childcare provider this form, duly completed and signed, together with each of the documents for which
the box has been checked on the back of this form so that a decision can be made as to your eligibility.
Section 1 – IDENTIFICATION
The holder of parental authority or the person who has custody of the child.
Parent
Last name
First name
Social Insurance Number
Home address
Number
Street, Avenue, Boulevard, P.O.Box
Apartment
Town/City, Municipality
Province
Postal code
Area code
Area code
Extension
Telephone number (home)
Telephone number (work)
What is your relationship
A
A and B
to the child or children?
Father
Mother
Other
Are you a Canadian citizen?
Yes
No
If you are submitting an application for more than two children, please use a second form and indicate the child’s rank (3rd, 4th, etc.).
First child
Second child
Last name
Last name
First name
First name
Year
Month
Day
Year
Month
Day
A
A
Date of birth
Date of birth
Section 2 – CHILDCARE NEEDS
Check (✔) the box that corresponds to your needs.
First child referred to in this application
Second child referred to in this application
Child under 5 years of age on September
E
Child under 5 years of age on September
E
30th of the reference year
30th of the reference year
Continuous period from 2 1/2 to 4 hours per day
Continuous period from 2 1/2 to 4 hours per day
Continuous period of more than 4 hours per day up to
Continuous period of more than 4 hours per day up to
a maximum of 10 hours per day
a maximum of 10 hours per day
F
F
Child 5 years of age or older on September 30 of the reference year,
Child 5 years of age or older on September 30 of the reference year,
who cannot be accommodated in a childcare service in a school daycare
who cannot be accommodated in a childcare service in a school daycare
environment due to the absence of such service or no available space
environment due to the absence of such service or no available space
Continuous period or interrupted periods totaling at least
Continuous period or interrupted periods totaling at least
2 1/2 hours per day for a maximum daycare period of 5 hours
2 1/2 hours per day for a maximum daycare period of 5 hours
per day between 6:30 a.m. and 6:30 p.m.
per day between 6:30 a.m. and 6:30 p.m.
Year
Month
Day
Year
Month
Day
Anticipated date of the first day
Anticipated date of the first day
of daycare
of daycare
Year
Month
Day
Year
Month
Day
Anticipated date of the end
Anticipated date of the end
of daycare (if you know it)
of daycare (if you know it)
Section 3 – FINANCIAL ASSISTANCE PROGRAMS
(Aim for Employment Program, Social Assistance Program, Social Solidarity Program, Alternative Youth Program, or Income
Security Program for Cree Hunters and Trappers)
Do you receive benefits under the Aim for Employment Program, the Social Assistance Program, the Social
3.1
Solidarity Program, or the Youth Alternative Program provided for by the Individual and Family Assistance
Act (Chapter A-13.1.1), or under the Income Security Program for Cree Hunters and Trappers?
Yes
C
No
If you answered No, go to Section 4 – INFORMATION REQUIRED IN THE CASE OF RE-ENROLLMENT
Please sign the authorization to release information if you receive benefits under a financial assistance program covered by this section.
I authorize the Ministère de la Famille to verify, within the context of the reduced contribution exemption, my eligibility for the Aim for Employment
Program, the Social Assistance Program, the Social Solidarity Program, the Youth Alternative Program, or the Income Security Program for Cree
Hunters and Trappers.
Year
Month
Day
Parent’s signature
Date
Section 4 – INFORMATION REQUIRED IN THE CASE OF RE-ENROLLMENT
4.1
Since September 1 of the reference year, have you benefited from the reduced contribution or, if you are
receiving benefits through a financial assistance program covered by Section 3, have you been exempted
Yes
D
No
from the payment of the reduced contribution?
Section 5 – SIGNATURE
I declare that the information appearing on this application is accurate and complete. Please note that under the Reduced Contribution Regulation,
the parent must immediately notify the childcare provider of any change affecting the information and the documents used to establish their eligibility for
the reduced contribution or for the exemption from its payment.
Year
Month
Day
Date
Parent’s signature
Ministère de la Famille
FO-0601A (07-2021)
Page 1 of 2
White copy : PERMIT HOLDER OR COORDINATING OFFICE — Yellow copy : PARENT
Application to determine eligibility for the reduced contribution
The letters in a square (example:
A
) appearing on this form refer to the list of documents to be attached.
It is important to check the boxes on the back of this form that correspond to your situation. You must give
the childcare provider this form, duly completed and signed, together with each of the documents for which
the box has been checked on the back of this form so that a decision can be made as to your eligibility.
Section 1 – IDENTIFICATION
The holder of parental authority or the person who has custody of the child.
Parent
Last name
First name
Social Insurance Number
Home address
Number
Street, Avenue, Boulevard, P.O.Box
Apartment
Town/City, Municipality
Province
Postal code
Area code
Area code
Extension
Telephone number (home)
Telephone number (work)
What is your relationship
A
A and B
to the child or children?
Father
Mother
Other
Are you a Canadian citizen?
Yes
No
If you are submitting an application for more than two children, please use a second form and indicate the child’s rank (3rd, 4th, etc.).
First child
Second child
Last name
Last name
First name
First name
Year
Month
Day
Year
Month
Day
A
A
Date of birth
Date of birth
Section 2 – CHILDCARE NEEDS
Check (✔) the box that corresponds to your needs.
First child referred to in this application
Second child referred to in this application
Child under 5 years of age on September
E
Child under 5 years of age on September
E
30th of the reference year
30th of the reference year
Continuous period from 2 1/2 to 4 hours per day
Continuous period from 2 1/2 to 4 hours per day
Continuous period of more than 4 hours per day up to
Continuous period of more than 4 hours per day up to
a maximum of 10 hours per day
a maximum of 10 hours per day
F
F
Child 5 years of age or older on September 30 of the reference year,
Child 5 years of age or older on September 30 of the reference year,
who cannot be accommodated in a childcare service in a school daycare
who cannot be accommodated in a childcare service in a school daycare
environment due to the absence of such service or no available space
environment due to the absence of such service or no available space
Continuous period or interrupted periods totaling at least
Continuous period or interrupted periods totaling at least
2 1/2 hours per day for a maximum daycare period of 5 hours
2 1/2 hours per day for a maximum daycare period of 5 hours
per day between 6:30 a.m. and 6:30 p.m.
per day between 6:30 a.m. and 6:30 p.m.
Year
Month
Day
Year
Month
Day
Anticipated date of the first day
Anticipated date of the first day
of daycare
of daycare
Year
Month
Day
Year
Month
Day
Anticipated date of the end
Anticipated date of the end
of daycare (if you know it)
of daycare (if you know it)
Section 3 – FINANCIAL ASSISTANCE PROGRAMS
(Aim for Employment Program, Social Assistance Program, Social Solidarity Program, Alternative Youth Program, or Income
Security Program for Cree Hunters and Trappers)
Do you receive benefits under the Aim for Employment Program, the Social Assistance Program, the Social
3.1
Solidarity Program, or the Youth Alternative Program provided for by the Individual and Family Assistance
Act (Chapter A-13.1.1), or under the Income Security Program for Cree Hunters and Trappers?
Yes
C
No
If you answered No, go to Section 4 – INFORMATION REQUIRED IN THE CASE OF RE-ENROLLMENT
Please sign the authorization to release information if you receive benefits under a financial assistance program covered by this section.
I authorize the Ministère de la Famille to verify, within the context of the reduced contribution exemption, my eligibility for the Aim for Employment
Program, the Social Assistance Program, the Social Solidarity Program, the Youth Alternative Program, or the Income Security Program for Cree
Hunters and Trappers.
Year
Month
Day
Parent’s signature
Date
Section 4 – INFORMATION REQUIRED IN THE CASE OF RE-ENROLLMENT
4.1
Since September 1 of the reference year, have you benefited from the reduced contribution or, if you are
receiving benefits through a financial assistance program covered by Section 3, have you been exempted
Yes
D
No
from the payment of the reduced contribution?
Section 5 – SIGNATURE
I declare that the information appearing on this application is accurate and complete. Please note that under the Reduced Contribution Regulation,
the parent must immediately notify the childcare provider of any change affecting the information and the documents used to establish their eligibility for
the reduced contribution or for the exemption from its payment.
Year
Month
Day
Date
Parent’s signature
Ministère de la Famille
FO-0601A (07-2021)
Page 1 of 2
White copy : PERMIT HOLDER OR COORDINATING OFFICE — Yellow copy : PARENT
LIST OF DOCUMENTS TO BE ATTACHED
Check (✓) the boxes that correspond to your situation according to the letters in a square appearing on the form.
The birth certificate of the parent or, in the case of a parent having Canadian citizenship, any other document establishing Canadian citizenship
A
(citizenship card, certificate of Canadian citizenship, Canadian passport, certificate of a Canadian birth abroad, certificate of Indian status).
The birth certificate of the first child referred to in this application.
A
The birth certificate of the second child referred to in this application.
A
IMPORTANT : Your birth certificate or, if applicable, the document establishing your Canadian citizenship, as well
as the birth certificate of your child or children must be submitted to the childcare provider. A photocopy,
certified as being a true copy of the original by the childcare provider, must be kept in the parent’s file.
B
If you are not a Canadian citizen and if you are unable to provide your birth certificate or that of your children, you will have to make a statement
under oath explaining the reasons why you are unable to provide these documents and specifying the date of birth of your child or children,
as the case may be. In addition, if you are not a Canadian citizen, please check (✓) the box pertaining to your status in the following table and
submit the required documents depending on your status.
TABLE OF ADDITIONAL DOCUMENTS REQUIRED FROM A PARENT WHO IS NOT A CANADIAN CITIZEN
Foreigners with a status
Person authorized to
submit an application
Refugee
Permanent
for permanent
Temporary
Foreign
Holder of a temporary
Person requiring protection
Resident
residence on site
Worker
student
residence permit
Protected person
Required documents
Required documents
Required documents
Required documents
Required documents
Required documents
Copy of record
Copy of the letter
Copy of the work
Copy of the certificate
Copy of the temporary
Copy of the selection
of landing
issued by Canadian
permit issued by
of acceptance issued
residence permit,
certificate issued
(IMM-1000)
immigration authorities
Canadian immigration
pursuant to section 3.2
whose codification
pursuant to section 3.1
establishing that the
authorities
of the Act respecting
establishes that it has been
of the Act respecting
or
person is authorized
immigration to Québec
issued for the possible
immigration to Québec
to submit in Canada
or
granting of permanent
Copy of the permanent
an application for
and
residence status
and
resident card
permanent residence
If the foreign national
is exempted from the
Copy of a letter from the
and
Copy of the letter
or
and
obligation of being
Ministre de l’Éducation et
from the appropriate
the holder of such a permit,
de l’Enseignement supérieur
Copy of the selection
Canadian authority
Copy of the
Copy of the selection
copy of the document
attesting that the person
certificate issued
establishing that the
confirmation of
certificate issued
attesting to his right
is a recipient of a bursary
pursuant to section 3.1
person is a refugee or a
permanent residence
pursuant to section 3.1
to be in Canada
from the Government of
of the Act respecting
person requiring protection
issued by Canadian
of the Act respecting
Québec in application of the
immigration to Québec
or a protected
immigration authorities
immigration to Québec
policy related to foreign
person under the
students in the colleges
Immigration and
and universities of Québec
Refugee Protection Act
Proof that you are receiving benefits under the Aim for Employment Program, the Social Assistance Program, the Social Solidarity Program,
C
or the Youth Alternative Program provided for by the Individual and Family Assistance Act (Chapter A-13.1.1), or under the Income Security
Program for Cree Hunters and Trappers.
An attestation of the daycare services received specifying notably the date when the child begins daycare, the date when daycare services
D
end, and the total number of days of childcare at a reduced contribution which you have benefited from since September 1 of the reference
year. If you receive benefits under the Aim for Employment Program, the Social Assistance Program, the Social Solidarity Program, the Youth
Alternative Program, or the Income Security Program for Cree Hunters and Trappers the total number of childcare days for which you have
been exempted from paying the reduced contribution.
A copy of the daycare agreement signed by the person in charge of a home daycare operation, where applicable.
E
An attestation signed by the principal of the school attended by the child, five years of age or over, on September 30 of the reference year
F
establishing the absence of a childcare service in a school daycare environment or the absence of an available space, whichever is the case.
RESERVED FOR THE ADMINISTRATION
DECISION OF THE PERMIT HOLDER OR THE HOME CHILDCARE COORDINATING OFFICE
Identification
Name of permit holder or coordinating office
Establishment number
Last name of the home childcare provider
First name
Decision
Yes The parent’s application is accepted; the parent meets all of the conditions stipulated in the Act or in the Reduced Contribution Regulation.
No The parent’s application is rejected for the following reasons:
To be completed if the parent receives benefits under a financial assistance program covered in Section 3
(Aim for Employment Program, the Social Assistance Program, the Social Solidarity Program, the Youth Alternative Program, or the Income Security Program
for Cree Hunters and Trappers)
The parent is exempted from the payment of the reduced contribution
Yes
No
First child referred to in this application
Second child referred to in this application
Year
Month
Day
Year
Month
Day
Date when daycare starts
Date when daycare starts
Year
Month
Day
Year
Month
Day
Date of the decision
Date of the decision
Year
Month
Day
Signature
Date
RIGHT TO REVIEW
A parent who feels that he has been wronged by the decision of a permit holder or a home daycare coordinating office can ask the Minister to review this decision. The application must be made in writing
and briefly outline the reasons given. It must be submitted to this address within 90 days following the date on which the parent is informed of the decision:
Secrétariat général, ministère de la Famille, 425, rue Jacques-Parizeau, Québec (Québec) G1R 4Z1.
Ministère de la Famille
FO-0601A (07-2021)
Page 2 of 2
White copy : PERMIT HOLDER OR COORDINATING OFFICE — Yellow copy : PARENT
Application to determine eligibility for the reduced contribution
The letters in a square (example:
A
) appearing on this form refer to the list of documents to be attached.
It is important to check the boxes on the back of this form that correspond to your situation. You must give
the childcare provider this form, duly completed and signed, together with each of the documents for which
the box has been checked on the back of this form so that a decision can be made as to your eligibility.
Section 1 – IDENTIFICATION
The holder of parental authority or the person who has custody of the child.
Parent
Last name
First name
Social Insurance Number
Home address
Number
Street, Avenue, Boulevard, P.O.Box
Apartment
Town/City, Municipality
Province
Postal code
Area code
Area code
Extension
Telephone number (home)
Telephone number (work)
What is your relationship
A
A and B
to the child or children?
Father
Mother
Other
Are you a Canadian citizen?
Yes
No
If you are submitting an application for more than two children, please use a second form and indicate the child’s rank (3rd, 4th, etc.).
First child
Second child
Last name
Last name
First name
First name
Year
Month
Day
Year
Month
Day
A
A
Date of birth
Date of birth
Section 2 – CHILDCARE NEEDS
Check (✔) the box that corresponds to your needs.
First child referred to in this application
Second child referred to in this application
Child under 5 years of age on September
E
Child under 5 years of age on September
E
30th of the reference year
30th of the reference year
Continuous period from 2 1/2 to 4 hours per day
Continuous period from 2 1/2 to 4 hours per day
Continuous period of more than 4 hours per day up to
Continuous period of more than 4 hours per day up to
a maximum of 10 hours per day
a maximum of 10 hours per day
F
F
Child 5 years of age or older on September 30 of the reference year,
Child 5 years of age or older on September 30 of the reference year,
who cannot be accommodated in a childcare service in a school daycare
who cannot be accommodated in a childcare service in a school daycare
environment due to the absence of such service or no available space
environment due to the absence of such service or no available space
Continuous period or interrupted periods totaling at least
Continuous period or interrupted periods totaling at least
2 1/2 hours per day for a maximum daycare period of 5 hours
2 1/2 hours per day for a maximum daycare period of 5 hours
per day between 6:30 a.m. and 6:30 p.m.
per day between 6:30 a.m. and 6:30 p.m.
Year
Month
Day
Year
Month
Day
Anticipated date of the first day
Anticipated date of the first day
of daycare
of daycare
Year
Month
Day
Year
Month
Day
Anticipated date of the end
Anticipated date of the end
of daycare (if you know it)
of daycare (if you know it)
Section 3 – FINANCIAL ASSISTANCE PROGRAMS
(Aim for Employment Program, Social Assistance Program, Social Solidarity Program, Alternative Youth Program, or Income
Security Program for Cree Hunters and Trappers)
Do you receive benefits under the Aim for Employment Program, the Social Assistance Program, the Social
3.1
Solidarity Program, or the Youth Alternative Program provided for by the Individual and Family Assistance
Act (Chapter A-13.1.1), or under the Income Security Program for Cree Hunters and Trappers?
Yes
C
No
If you answered No, go to Section 4 – INFORMATION REQUIRED IN THE CASE OF RE-ENROLLMENT
Please sign the authorization to release information if you receive benefits under a financial assistance program covered by this section.
I authorize the Ministère de la Famille to verify, within the context of the reduced contribution exemption, my eligibility for the Aim for Employment
Program, the Social Assistance Program, the Social Solidarity Program, the Youth Alternative Program, or the Income Security Program for Cree
Hunters and Trappers.
Year
Month
Day
Parent’s signature
Date
Section 4 – INFORMATION REQUIRED IN THE CASE OF RE-ENROLLMENT
4.1
Since September 1 of the reference year, have you benefited from the reduced contribution or, if you are
receiving benefits through a financial assistance program covered by Section 3, have you been exempted
Yes
D
No
from the payment of the reduced contribution?
Section 5 – SIGNATURE
I declare that the information appearing on this application is accurate and complete. Please note that under the Reduced Contribution Regulation,
the parent must immediately notify the childcare provider of any change affecting the information and the documents used to establish their eligibility for
the reduced contribution or for the exemption from its payment.
Year
Month
Day
Date
Parent’s signature
Ministère de la Famille
FO-0601A (07-2021)
Page 1 of 2
White copy : PERMIT HOLDER OR COORDINATING OFFICE — Yellow copy : PARENT
LIST OF DOCUMENTS TO BE ATTACHED
Check (✓) the boxes that correspond to your situation according to the letters in a square appearing on the form.
The birth certificate of the parent or, in the case of a parent having Canadian citizenship, any other document establishing Canadian citizenship
A
(citizenship card, certificate of Canadian citizenship, Canadian passport, certificate of a Canadian birth abroad, certificate of Indian status).
The birth certificate of the first child referred to in this application.
A
The birth certificate of the second child referred to in this application.
A
IMPORTANT : Your birth certificate or, if applicable, the document establishing your Canadian citizenship, as well
as the birth certificate of your child or children must be submitted to the childcare provider. A photocopy,
certified as being a true copy of the original by the childcare provider, must be kept in the parent’s file.
B
If you are not a Canadian citizen and if you are unable to provide your birth certificate or that of your children, you will have to make a statement
under oath explaining the reasons why you are unable to provide these documents and specifying the date of birth of your child or children,
as the case may be. In addition, if you are not a Canadian citizen, please check (✓) the box pertaining to your status in the following table and
submit the required documents depending on your status.
TABLE OF ADDITIONAL DOCUMENTS REQUIRED FROM A PARENT WHO IS NOT A CANADIAN CITIZEN
Foreigners with a status
Person authorized to
submit an application
Refugee
Permanent
for permanent
Temporary
Foreign
Holder of a temporary
Person requiring protection
Resident
residence on site
Worker
student
residence permit
Protected person
Required documents
Required documents
Required documents
Required documents
Required documents
Required documents
Copy of record
Copy of the letter
Copy of the work
Copy of the certificate
Copy of the temporary
Copy of the selection
of landing
issued by Canadian
permit issued by
of acceptance issued
residence permit,
certificate issued
(IMM-1000)
immigration authorities
Canadian immigration
pursuant to section 3.2
whose codification
pursuant to section 3.1
establishing that the
authorities
of the Act respecting
establishes that it has been
of the Act respecting
or
person is authorized
immigration to Québec
issued for the possible
immigration to Québec
to submit in Canada
or
granting of permanent
Copy of the permanent
an application for
and
residence status
and
resident card
permanent residence
If the foreign national
is exempted from the
Copy of a letter from the
and
Copy of the letter
or
and
obligation of being
Ministre de l’Éducation et
from the appropriate
the holder of such a permit,
de l’Enseignement supérieur
Copy of the selection
Canadian authority
Copy of the
Copy of the selection
copy of the document
attesting that the person
certificate issued
establishing that the
confirmation of
certificate issued
attesting to his right
is a recipient of a bursary
pursuant to section 3.1
person is a refugee or a
permanent residence
pursuant to section 3.1
to be in Canada
from the Government of
of the Act respecting
person requiring protection
issued by Canadian
of the Act respecting
Québec in application of the
immigration to Québec
or a protected
immigration authorities
immigration to Québec
policy related to foreign
person under the
students in the colleges
Immigration and
and universities of Québec
Refugee Protection Act
Proof that you are receiving benefits under the Aim for Employment Program, the Social Assistance Program, the Social Solidarity Program,
C
or the Youth Alternative Program provided for by the Individual and Family Assistance Act (Chapter A-13.1.1), or under the Income Security
Program for Cree Hunters and Trappers.
An attestation of the daycare services received specifying notably the date when the child begins daycare, the date when daycare services
D
end, and the total number of days of childcare at a reduced contribution which you have benefited from since September 1 of the reference
year. If you receive benefits under the Aim for Employment Program, the Social Assistance Program, the Social Solidarity Program, the Youth
Alternative Program, or the Income Security Program for Cree Hunters and Trappers the total number of childcare days for which you have
been exempted from paying the reduced contribution.
A copy of the daycare agreement signed by the person in charge of a home daycare operation, where applicable.
E
An attestation signed by the principal of the school attended by the child, five years of age or over, on September 30 of the reference year
F
establishing the absence of a childcare service in a school daycare environment or the absence of an available space, whichever is the case.
RESERVED FOR THE ADMINISTRATION
DECISION OF THE PERMIT HOLDER OR THE HOME CHILDCARE COORDINATING OFFICE
Identification
Name of permit holder or coordinating office
Establishment number
Last name of the home childcare provider
First name
Decision
Yes The parent’s application is accepted; the parent meets all of the conditions stipulated in the Act or in the Reduced Contribution Regulation.
No The parent’s application is rejected for the following reasons:
To be completed if the parent receives benefits under a financial assistance program covered in Section 3
(Aim for Employment Program, the Social Assistance Program, the Social Solidarity Program, the Youth Alternative Program, or the Income Security Program
for Cree Hunters and Trappers)
The parent is exempted from the payment of the reduced contribution
Yes
No
First child referred to in this application
Second child referred to in this application
Year
Month
Day
Year
Month
Day
Date when daycare starts
Date when daycare starts
Year
Month
Day
Year
Month
Day
Date of the decision
Date of the decision
Year
Month
Day
Signature
Date
RIGHT TO REVIEW
A parent who feels that he has been wronged by the decision of a permit holder or a home daycare coordinating office can ask the Minister to review this decision. The application must be made in writing
and briefly outline the reasons given. It must be submitted to this address within 90 days following the date on which the parent is informed of the decision:
Secrétariat général, ministère de la Famille, 425, rue Jacques-Parizeau, Québec (Québec) G1R 4Z1.
Ministère de la Famille
FO-0601A (07-2021)
Page 2 of 2
White copy : PERMIT HOLDER OR COORDINATING OFFICE — Yellow copy : PARENT
Page of 4