Cleaning and Supplies for Child Care Providers (CSCP) Self-Certification Form

Cleaning and Supplies for Child Care Providers (CSCP) Self-Certification Form
Based on the California Department of Education’s guidelines, child care providers are eligible to receive $65.89 per child served to purchase and/or receive cleaning supplies and services.

Each child care provider has the option to request funding in one of the following ways:
- 100% funding
- 50% funding / 50% supplies
- 100% supplies
If you choose 100% funding, you will receive $65.89 per child served while funds last. Current providers will receive funds via direct deposit into the bank account or pay card on file. New providers will receive a physical check mailed to the address you provide here. Payments may take up to 10 business days to process and deliver by direct deposit, pay card, and mail.

If you choose 50% funding / 50% supplies, you will receive $32.95 per child served in funds and $32.95 worth of supplies. Due to limited availability, supplies may vary per provider.

If you choose cleaning supplies, you will not receive a payment of funds from CCRC. For each child served, you will receive $65.89 in supplies which will be available for pickup within 6-8 weeks from the time you submit your CSCP Self-Certification Form. Pick up will be BY APPOINTMENT ONLY. CCRC staff will contact you to schedule the location, date and time. Supplies MAY include: disposable masks, disposable gloves, bleach, disinfectant wipes, paper towels, and hand sanitizer.

These funds and supplies can only be distributed to providers who are currently open or plan to reopen during COVID-19 within CCRC's service area. If you are not open and do not plan to open, you will not be eligible for these funds.

If you have multiple child care locations, please submit 1 form per location. Please submit only 1 self-certification form per child care provider site. Self-certification forms cannot be changed after they have been submitted. Duplicate forms received for the same child care provider site will be not be approved.
Do you want to receive funds, supplies, or a combination of funds and supplies? (Funds take up to 10 business days to arrive; Supplies take 6-8 weeks to be ready to pick up) *

100% Funds 100% Supplies 50% Funds / 50% Supplies

Are you currently receiving child care payment or reimbursement from CCRC? *

Yes No
Do you receive your subsidies from CCRC through a direct deposit, pay card, or check? *

Direct Deposit Pay Card Check
Has your direct deposit or pay card information changed since you last received a payment from CCRC? *

Yes No

Based on the information you have provided, CCRC will provide your funds via direct deposit or pay card based on the information we have on file for you.
I certify that CCRC is allowed to submit a direct deposit to my bank account or pay card. Signature: *

Clear
Based on the information you have provided, CCRC will mail you a physical check to the address you provide in this form.
Name of Facility or Provider *
What type of provider are you? *

Licensed Center License Exempt Center Licensed Family Child Care Home Family, Friend, or Neighbor; or License Exempt Home Based
Facility License Number (if applicable)
What is your Provider Identification Number (PID)? You may find it on a previous timesheet.
We need to collect either your Taxpayer Identification Number, Employment Identification Number (EIN), or Social Security Number for tax purposes. Please indicate which you would like to provide. *

Taxpayer Identification Number or Employment Identification Number (EIN) Social Security Number
What is your Social Security Number? (Please enter as ###-##-####) *
What is your Taxpayer Identification Number or Employment Identification Number (EIN)? (Please enter as ##-#######) *
What is the street address where child care is provided? (e.g. 1900 Holly ave.) *
What is the city where child care is provided? (e.g. Chatsworth) *
What is the state where child care is provided?
What is the zip code where child care is provided? (e.g. 91311) *
What is the county where child care is provided? *

Los Angeles San Bernardino
Is your mailing address different from the above address? *

Yes No
What is your mailing address street? (e.g. 1900 Holly ave.) *
What is your mailing address city? (e.g. Chatsworth) *
What is your mailing address state?
What is your mailing address zip code? (e.g. 91311) *
What is your name? (First and Last name): *
What is your main contact phone number? *
What is your email address?: *
example@example.com
Are you currently open and caring for children? *

Yes No
What was your open date during COVID-19? (If you never closed, enter 03/20/2020): *

Month Day Year
Date
What is your planned reopen date? (if temporarily closed due to COVID-19): *

Month Day Year
Date
Total Capacity of Children Served OR Number of Children in Care (Whichever is higher) *
Number of Children in Care *
Supplies Received
Funds Received
I understand, as a provider, that this self-certification form is a requirement to receive CSCP funds, supplies, or both to serve essential workers and/or at-risk populations during the COVID-19 pandemic. As stated on this form, my program currently is open or will be open by the date specified and the funds and/or supplies will be used solely for these restricted purposes.
Signature of Licensee/Exempt Provider: *

Clear
I certify that all information provided on this form is true and complete. I agree to provide additional information, if requested, to verify accuracy.

Providing misleading or false information will result in the immediate revocation and return of funds / supplies to CCRC.

I certify that I am the person providing the electronic signature herein.
Signature of Licensee/Exempt Provider: *

Clear
Today’s Date: *

Month Day Year
Date
For Office Use Only

Do not check the box below unless you are a Child Care Resource Center employee.
Office Use

Check here if you are a CCRC staff member.
Date Received:

Month Day Year
Date
Date Verified by Staff: *

Month Day Year
Date Hour Minutes AM/PM Option
Approval Status *

Approve Denied
Staff Signature:

Clear
Should be Empty:

Cleaning and Supplies for Child Care Providers (CSCP) Self-Certification Form

For Office Use Only