"Consent to Exchange Information - Child Care Financial Assistance Program" - Vermont

Consent to Exchange Information - Child Care Financial Assistance Program is a legal document that was released by the Vermont Department of Children and Families - a government authority operating within Vermont.

Form Details:

  • Released on February 1, 2010;
  • The latest edition currently provided by the Vermont Department of Children and Families;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Vermont Department of Children and Families.

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Child Care Financial Assistance Program
Consent to Exchange Information
Client name: _________________________________________________________________
I give my permission for the eligibility specialists to exchange information required to
determine my/our eligibility for Child Care Financial Assistance Program with:
Department for Children and Families, Office of Child Support
Department for Children and Families, Economic Services Division
Department of Labor, formerly the Department of Employment & Training
Department for Children and Families, Family Services Division
Vocational Rehabilitation
Child care provider ________________________________ (provider’s name)
Employer ________________________________________ (employer’s name)
Family Support team
Essential Early Education (EEE)
Visiting Nurses Association (vna)
Other ____________________________________________
Relationship to child(ren) covered by consent form:
Mother
Father
Legal guardian
Other ________________
Or check here: ____ if you choose not to give consent.
______________________________________________
______________________
Signature
Date
Form must be returned with the application, for eligibility to be processed.
Please return this form to:
http://dcf.vermont.gov/cdd
Agency of Human Services
Revised 2/1/2010
Child Care Financial Assistance Program
Consent to Exchange Information
Client name: _________________________________________________________________
I give my permission for the eligibility specialists to exchange information required to
determine my/our eligibility for Child Care Financial Assistance Program with:
Department for Children and Families, Office of Child Support
Department for Children and Families, Economic Services Division
Department of Labor, formerly the Department of Employment & Training
Department for Children and Families, Family Services Division
Vocational Rehabilitation
Child care provider ________________________________ (provider’s name)
Employer ________________________________________ (employer’s name)
Family Support team
Essential Early Education (EEE)
Visiting Nurses Association (vna)
Other ____________________________________________
Relationship to child(ren) covered by consent form:
Mother
Father
Legal guardian
Other ________________
Or check here: ____ if you choose not to give consent.
______________________________________________
______________________
Signature
Date
Form must be returned with the application, for eligibility to be processed.
Please return this form to:
http://dcf.vermont.gov/cdd
Agency of Human Services
Revised 2/1/2010