MISSING INFORMATION NOTICE

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Rebecca Park
5 years ago
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MISSING INFORMATION NOTICE Date Parent One Address One Address Two (if necessary) City, State Zip Payment Address: FLORIDA KIDCARE P.O. BOX 31105 TAMPA, FL 33631-3105 Correspondence Address: FLORIDA KIDCARE P.

1 MISSING INFORMATION NOTICE Date Parent One Address One Address Two (if necessary) City, State Zip Payment Address: FLORIDA KIDCARE P.O. BOX TAMPA, FL Correspondence Address: FLORIDA KIDCARE P.O. BOX 591 TALLAHASSEE, FL Teletypewriter (TTY) RE: FAMILY ACCOUNT NUMBER XXXXXXXXXX Dear Parent One: We are reviewing your Florida KidCare account. We need more information to complete this review. You can call us with the information listed below at This call is free. Social security number for Parent Two. (this information is not required but may help us process your application faster) Social security number or date applied for Social Security number for Child B. You must send us the information listed below: Proof of income from work for Parent One. We accept: 1. Pay stubs or wage statements for the last four weeks, OR 2. A letter from your employer that says how much you earned before taxes, OR 3. Most recent federal income tax return, OR 4. Most recent W-2 forms Please provide proof of self-employment income for Parent Two. We accept: 1. Most recent federal income tax return (including all schedules filed with your return), or 2. Business ledgers, or 3. Records, or 4. Receipts, or 5. Tax statements. Write your family account number XXXXXXXXXX on each document you send us. Do not send original documents. Be sure to send readable copies.

2 There are three ways to send documents: By Fax: By By Mail: (This call is free) Florida KidCare P.O. Box 591 Tallahassee, FL To help us identify you, please return the last page of this letter with the information you send. (If possible, please keep a copy for yourself.) Your children s coverage may be canceled if we do not receive this information. If coverage has been canceled, your children may not qualify for future coverage. If you have any questions, please call us at This call is free. Sincerely, FLORIDA KIDCARE

3 Return this portion of the letter when submitting the requested information to help us ensure the timely and accurate updates to your account XXXXXXXXXX Si usted prefiere recibir su correspondencia en español, por favor llámenos al Esta llamada es sin cargo. Si w prefere resevwa enfòmasyon sa an kreyòl, tanpri rele nou nan Koutfil sa a gratis. T04b

SELF EMPLOYMENT STATEMENT Directions: Complete this form if you or another household member are self-employed. This form must be signed by the self-employed household member(s). Use blue or blank ink.

5 SELF EMPLOYMENT STATEMENT Directions: Complete this form if you or another household member are self-employed. This form must be signed by the self-employed household member(s). Use blue or blank ink. Return the completed form to Florida KidCare, P.O. Box 591, Tallahassee, Florida If you have any questions, please call us at This call is free. Family Account Number: Name of Family Member(s) who are Self-Employed: XXXXXXXXXX Parent Two Name of Business: Type of Business: Total gross (before taxes) self-employment income for the most recent month: $ Write in your business expenses for all of the items below for the most recent month: ALLOWABLE BUSINESS EXPENSES Advertising $ Business License $ Business Telephone Cost & Business Utilities Cost $ Business Transportation (NOT to and from work) $ Cost of Raw Materials, Farm Supplies & Feed, and Stock $ Cost of Employees Benefits $ Employer's FICA Share $ Employees' Wages $ Interest of Farm/Business Loan $ Insurance on Property and Equipment $ IRS Allowable Business Expense $ Legal Fees for Business $ Meals and Equipment for Children in Day Care (for Day Care Business ONLY) $ Operating Costs for Motor Vehicles for Business (gas, oil, etc.) $ Office Supplies and Tools for Business $ Postage $ Property Taxes on Income Producing Property $ Rent for Building, Land, and/or Machinery/Equipment for Business $ Repairs/Maintenance Equipment/Business Property $ Travel/Lodging Away from Home $ Tax Preparation Fee for Business $ TOTAL BUSINESS EXPENSES FOR THE MOST RECENT MONTH: $ AMOUNT If your self-employment income and expenses usually are different from what you have listed, use this space to tell us about the difference. Parent Statement: I certify that the information provided on this Self-Employment Statement is true and correct to the best of my knowledge. I understand that this information may be verified. I understand if I provide false information I may be prosecuted for fraud. Self-Employed Parent Signature Date Si usted prefiere recibir su correspondencia en español, por favor llámenos al Esta llamada es sin cargo. Si w prefere resevwa enfòmasyon sa an kreyòl, tanpri rele nou nan Koutfil sa a gratis.

6 Si usted prefiere recibir su correspondencia en español, por favor llámenos al Esta llamada es sin cargo. Si w prefere resevwa enfòmasyon sa an kreyòl, tanpri rele nou nan Koutfil sa a gratis.

7 FLORIDA KIDCARE EMPLOYMENT STATEMENT Provide a copy of this form to each employer that pays a household member. Complete Section A and submit to employer for completion. Return the completed form to Florida KidCare, P.O. Box 591, Tallahassee, FL Or Fax it to (This is a free fax line) Section A - To Be Completed by Employee Family Account Number: XXXXXXXXXX I authorize the release of employment information for the purpose of determining Florida KidCare eligibility. Employee Signature: Date: Employee Name: Parent One Employee SSN: XXX-XX-XXXX (Please print) Section B - To Be Completed by Employer Please answer the following questions for the employee listed above. (1) Number of Hours Worked Per Week: Number of Days Worked Per Week: (2) How often is the employee paid: Daily Weekly Bi-Weekly Monthly Twice Monthly Other (explain) (3) Rate of gross pay: $ per Hour/Day/Week/etc. Other (4) If hours or rate of pay has varied in the above period, please state why (include tip information here): (explain) Employer Statement: What I have written on this form is true to the best of my knowledge. I know that if I give false information on purpose, I may be subject to prosecution for fraud. Signature of Employer Employer's Title Name of Employer (please print) ( ) Employer's Telephone Number Name of Business Date Completed Business Address City, State, Zip

Dear Parent/Guardian:

303-313 Washington St. Auburn, MA 01501 1-800-222-2731 Fax 508-721-0919 E-mail: yfci@yoursforchildren.com Dear Parent/Guardian: Young children need healthy meals to learn. This letter is intended for parents