Please read all instructions and guidance on the Temporary Assistance for Stabilization of Child Care-4 (TASCC-4) Grant page before completing this form.

A copy of the facility’s W-9 is required for processing of this application. Additionally, if you elect to receive your grant via direct deposit, you must complete and return a copy of the ACH form. Both of these forms are available for download on the CCWS Grant page.

Read and acknowledge the terms of receiving this grant benefit. Sign and date the application prior to submission.

By submitting this Application and/or accepting funds distributed pursuant to this Application, the undersigned, its employees, agents, subcontractors, and assigns certifies and agrees:

1. To be bound by any and all terms set forth in this Application and to use any and all funds distributed pursuant to this Application in the manner set forth below;
2. This Application does not create a contractual relationship with the State of Alabama or any of its Agencies and any failure to distribute funds pursuant to this Application does not create a cause of action nor does it carry any appeal rights;
3. To only expend the funds in a manner on allowable categories as defined in the instructions;
4. To comply with all Minimum Standards for Daycare Centers and Nighttime Homes, and Group Day Care Homes, Group Nighttime Homes Regulations and Procedures;
5. To keep detailed, accurate, and truthful accounting records of the receipt, use, and disbursement of all funds received pursuant to this Application;
6. To allow DHR or its representatives unlimited access to audit and examine any and all records related to the funds disbursed pursuant to this Application, including, but not limited to, all records, reports, distributions, account ledgers, balance sheets, bank records, credit card statements, electronic payment records, receipts, or other documents related to the receipt and distribution of funds pursuant to this Application; failure to provide accurate documentation will be construed as filing a false statement;
7. To allow DHR or its representatives to interview any employee or agency in relation to funds disbursed pursuant to this Application;
8. That any funds received pursuant to this Application are subject to repayment, reclaim and recapture if (a) the funds are not used in the manner provided for and set forth in this Application, or (b) if access to records or information as set forth in the preceding paragraphs is refused or denied by the person(s) or entity receiving funds pursuant to this Application or, (c) if any information provided in the Application is found to be false or misleading; any agency action in requesting or demanding repayment, reclaim, and/or recapture is a final determination and is not subject to appeal;
9. That this is an Application for a continuing benefit under its existing child care license and its lawful presence in the State of Alabama, to the extent required, has been previously established;
10. That if funding is reduced or restricted prior to distribution by legislative action, federal or state allocations, or executive action, the amount distributed under this Agreement will be reduced or eliminated accordingly;
11. That this Agreement does not and will not violate any conflict of interest provisions in any respect and agrees not to employ an individual that would result in a violation of this law;
12. Will not use any funds disbursed under this application for lobbying or any other prohibited use;
13. To comply with Executive Order No. 11246, as amended and as supplemented by U.S. Department of Labor regulations (41 CFR, Part 60-1, et. seq.), which prohibits discrimination based on race, creed, color, religion, national origin, sex, or age;
14. If any provisions or paragraphs of this Application are or become illegal, unenforceable, or invalid, in whole or in part for any reason, the remainder of this Application shall remain in full force and effect without being impaired or invalidated in any way;
15. The information included in this Application is true and correct to the best of my knowledge;
16. To remain open for one year from the date of the grant award;
17. The person whose signature is below is the applicant/owner/licensee or the authorized designee with the authority to sign the Application.

A copy of your completed application will be emailed to the email address provided above for your records. Please be sure to check your inbox and (if necessary) spam folder for this important email.