Child Care Funds OUR CHILDREN, OUR FUTURE

1199SEIU Child Care Funds OUR CHILDREN, OUR FUTURE

WEEKEND CULTURAL ARTS PROGRAMS • CHILD CARE LEARNING CENTER

SUMMER DAY CAMP SITES • VOUCHER PROGRAMS • HOLIDAY PROGRAMS • TEEN PROGRAMS 1199SEIU Greater New York Benefit Fund 2017 Registration Information Booklet (Addendum to Summary Plan Description) Register In Person or Online Saturday, September 10, 2016 – Monday, October 31, 2016 PLEASE BE SURE TO BRING COPIES OF THE FOLLOWING DOCUMENTS: ❑ Your completed and signed application ❑ Current copy of your 1199SEIU Health Benefits ID card with dependents listed ❑ Completed and signed W-4 Form ❑ Copies of your two (2) most recent pay stubs dated within the last 30 days ❑ Copy of Social Security card of each child for whom you are applying

Alternate documents are listed on page 9.

Online registration begins on Thursday, September 1, 2016.

Child Care Fund Programs and Policies Table of Contents Your Guide to Selecting the Best Programs for Your Child...... 4

Registration Dates and Sites: September and October 2016...... 5

2016 Registration Locations and Schedules...... 6

Child Care Fund Introduction...... 8

Eligibility and Consideration for Benefits...... 8

Required Documentation for Registration...... 9

Registering for Child Care Fund Programs Registering in Person and Registering Online...... 10

Benefit Distribution and Notification...... 10

Loss of Approved Benefits...... 11

Procedures Requiring Written Notification from the Member Dropping and Changing an Approved Program...... 11

Change of Address, Name and Tax Status...... 11

Payment Policy Co-payments and Refunds...... 12

Programs Choosing a Program that Is Right for Your Child...... 13

Multiple Benefits...... 13

Special Needs...... 13

Children and Youth Programs/Services Offered by the Child Care Fund Resources and Support for Members and Children...... 13

Year-Round Programs Child Care Learning Center (CCLC)/Future of America Learning Center (FALC)...... 14 Voucher Reimbursements, After School Voucher (ASV), Day Care Voucher (DCV)...... 15 WorkForce 2000 (WF2)...... 16 Weekend Programs Cultural Arts Program (CAP), Cultural Arts Stipend Program (CASP)...... 17 SAT Prep (SAT)...... 17 Holiday Programs Holiday Program (HP), Holiday Sleep-Away Program (HSAP)...... 17 Summer Programs Summer Day Camp (SDC), Special Needs Summer Day Camp (SNSDC)...... 18 Summer Day Camp Voucher (SDCV), Special Needs Summer Day Camp Voucher (SNSDCV)...... 19

Tax Liability...... 20 Appendices Appendix A: Tax Certification Worksheet for Dependent Care Expenses...... 21 Appendix B: Sample Application ...... 22 Appendix C: Sample Program Status Letter...... 26 Your Guide to Selecting the Best Programs for Your Child Please refer to this guide when completing your program application.

Age Provider Name Number Co-payment or Program Name Program Description Range and Location of Weeks Reimbursement After School Voucher 6–12 yrs. Members are reimbursed a portion Documented: Licensed Provider 40 weeks Quarterly Documented (ASV-D) of after school program expenses. Undocumented: Unlicensed Provider School year: reimbursement; Undocumented (ASV-U) Sept. – June Doc. rate: $30/wk Undoc. rate: $20/wk Child Care Learning 18 mos. – Early childhood center provides Future of America Learning Center 51 weeks Weekly co-payment Center (CCLC) / 5 yrs. full day of age-appropriate learning 2500 Creston Avenue, Third Floor based on sliding fee Future of America activities and play. Bronx, NY 10468 scale. See scale on Learning Center (FALC) BRONX SITE ONLY (718) 562-2915 page 14. Cultural Arts Program 5–17 yrs. Weekend cultural and academic Select from Service Provider Booklet Varies Co-payment: $100 (CAP) programs are available for the (yellow booklet) children of members who work weekends. Various providers offer a variety of enriching classes in recreational sports, academics, and visual and performing arts. Cultural Arts Stipend 5–17 yrs. Weekend program for children of Member chooses provider. Varies Yearly Program (CASP) members who work weekends. See criteria listed on page 17. reimbursement; $700 maximum amount Day Care Voucher Birth – Members are reimbursed a portion Documented: Licensed Provider 52 weeks Quarterly Documented (DCV-D) 5 yrs. of day care program expenses. Undocumented: Unlicensed Provider reimbursement; Undocumented (DCV-U) See scale on page 16. SAT Prep (SAT) 11th Saturday morning classes designed to Member selects preferred site: Bronx, 21-week Co-payment: $100 prepare 11th graders for all aspects of Brooklyn, Long Island, Manhattan program (both graders Benefit is taxable. only the SAT exams. or Queens spring and fall sessions are required) Summer Day Camp 3–17 yrs. Licensed camps provide summer Select from Service Provider Booklet Varies Weekly co-payment; (SDC) programs to children. (yellow booklet) See scale on page 18. Special Needs 3–17 yrs. Special needs camps provide Member chooses provider. CCR&R can Varies Weekly co-payment; Summer Day Camp programs to eligible children. assist in search. Call (212) 564-2220. See scale on page 18. (SNSDC) Summer Day Camp 3–17 yrs. Camps for those who live outside Member chooses provider. CCR&R can Up to a Weekly Voucher (SDCV) the New York City metropolitan area assist in search. Call (212) 564-2220. maximum of reimbursement; or who have dietary or religious 8 weeks See scale on page 19. restrictions. Special Needs Summer 3–17 yrs. Special needs camps provide Member chooses provider. CCR&R can Up to a Contact CCR&R for Day Camp Voucher programs to eligible children. assist in search. Call (212) 564-2220. maximum of reimbursement rates. (SNSDCV) 8 weeks Call (212) 564-2220. WorkForce 2000 14–17 yrs., Teens prepare for college/careers by Metropolitan Center for Research Year-round No co-payment (WF2) 8th–11th participating in academic sessions, on Equity and the Transformation of program Benefit is taxable. graders workshops and unpaid internships, Schools (Metro Center) and are exposed to cultural New York University experiences and community service 726 Broadway, 5th Floor opportunities. New York, NY 10003 Holiday Program (HP) 3–15 yrs. Provides full-day camp services for Select from Service Provider Booklet Winter, Co-payment: $25 winter, spring and December school (yellow booklet) spring and breaks. December breaks Holiday Sleep-Away 8–17 yrs. Participants attend a five-day (5) Participants attend an American Camp Winter and Co-payment based on Program (HSAP) and four-night (4) sleep-away camp Association-accredited camp facility. spring breaks sliding fee scale. See program. Program activities include Facility has a heated living area, as well only; based scale on page 18. recreational sports, arts and crafts, as indoor and outdoor program spaces on the NYC Benefit is taxable. and nature activities. to ensure all participants have a safe, fun public school and educational experience. calendar

4 Registration Dates and Sites: September and October 2016 When seeking dates and times for your preferred registration site, please note the calendar code, or abbreviation for each site, listed on pages 6–7. For the expanded listing of registration sites and dates, visit www.1199SEIUBenefits.org/ccf. Online registration begins Thursday, September 1, 2016.

Monday Tuesday Wednesday Thursday Friday Saturday 1 2 3 ONLINE REGISTRATION BEGINS 5 6 7 8 9 10 LABOR DAY REGISTRATION KICKOFF CCF CLOSED Union Headquarters: 10:00 am – 4:00 pm

12 13 14 15 16 17 CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm HICKSVILLE KICKOFF: HO: CLOSED HO: 9:00 am – 6:00 pm HO: CLOSED HO: 9:00 am – 7:00 pm HO: CLOSED 9:00 am – 12:30 pm FP: 9:00 am – 7:00 pm FP: 9:00 am – 7:00 pm RR: 8:30 am – 7:30 pm BC | JW: 9:00 am – 7:00 pm CCF: 9:00 am – 4:00 pm

SEPTEMBER BC: 9:00 am – 4:00 pm 19 20 21 22 23 24 CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 9:00 am – 4:00 pm HO: CLOSED HO: 9:00 am – 6:00 pm HO: CLOSED HO: 9:00 am – 7:00 pm HO: CLOSED HO: 9:00 am – 12:30 pm JW: 9:00 am – 7:00 pm SI | WP: 9:00 am – 7:00 pm FALC: 10:00 am – 4:00 pm SI: 9:00 am – 4:00 pm 26 27 28 29 30 CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm HO: CLOSED HO: 9:00 am – 6:00 pm HO: CLOSED HO: 9:00 am – 7:00 pm HO: CLOSED MC: 8:30 am – 5:30 pm MC: 8:30 am – 5:30 pm JH: 8:30 am – 7:00 pm

Monday Tuesday Wednesday Thursday Friday Saturday 1 CCF: 9:00 am – 4:00 pm HO: 9:00 am – 12:30 pm JH: 9:00 am – 4:00 pm 3 4 5 6 7 8 CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 9:00 am – 4:00 pm HO: CLOSED HO: 9:00 am – 6:00 pm HO: CLOSED HO: 9:00 am – 7:00 pm HO: CLOSED HO: 9:00 am – 12:30 pm MH: 9:00 am – 12:00 pm FP: 9:00 am – 7:00 pm FP: 9:00 am – 7:00 pm WP: 9:00 am – 7:00 pm MH: 9:00 am – 7:00 pm and 1:30 pm – 5:00 pm AO: 9:00 am – 5:00 pm 10 11 12 13 14 15 CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 9:00 am – 4:00 pm HO: CLOSED HO: 9:00 am – 6:00 pm HO: CLOSED HO: 9:00 am – 7:00 pm HO: CLOSED HO: 9:00 am – 12:30 pm OCTOBER JW: 9:00 am – 7:00 pm SH: 7:00 am – 4:00 pm BC | JW: 9:00 am – 7:00 pm BC: 9:00 am – 4:00 pm UR: 8:30 am – 2:00 pm FALC: 10:00 am – 4:00 pm 17 18 19 20 21 22 CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 9: 00 am – 4:00 pm HO: CLOSED HO: 9:00 am – 6:00 pm HO: CLOSED HO: 9:00 am – 7:00 pm HO: CLOSED HO: 9:00 am – 12:30 pm SI: 9:00 am – 7:00 pm JH | SI: 9:00 am – 4:00 pm JH: 8:30 am – 7:00 pm 24 25 26 27 28 29 CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 8:30 am – 7:00 pm CCF: 9:00 am – 4:00 pm HO: CLOSED HO: 9:00 am – 6:00 pm HO: CLOSED HO: 9:00 am – 7:00 pm HO: 9:00 am – 7:00 pm HO: 9:00 am – 12:30 pm

31 REGISTRATION ENDS CCF: 9:00 am – 4:00 pm HO: 9:00 am – 4:00 pm

5 2016 Registration Locations and Schedules

Locations and Directions Dates Calendar Code Times 1199SEIU Child Care Funds September 10 – October 31 CCF 330 West 42nd Street, 18th Floor Monday through Friday 8:30 am – 7:00 pm New York, NY 10036 (212) 564-2220 Saturdays 9:00 am – 4:00 pm Subway: Take the A, C, D, E, F, N, Q, R, S, #1, #2, #3 or Closed Sundays #7 train to 42nd Street station. Site is located next to the Port Authority on 42nd Street. 1199SEIU Child Care Funds (Hicksville Office) September 17 – October 31 HO 100 Duffy Avenue, 3rd Floor Tuesdays 9:00 am – 6:00 pm Hicksville, NY 11801 (516) 229-6700, ext. 2730 Thursdays 9:00 am – 7:00 pm Train: Take the Long Island Rail Road to Hicksville station. Friday, October 28 9:00 am – 7:00 pm Bus: Take the N20, N21, N22, N48, N49, N50, N73, N74, Saturdays 9:00 am – 12:30 pm N78, N79, N80, N81 or N94 to the Hicksville Long Island Rail Road station. Closed Mondays, Wednesdays, Fridays and Sundays

1199SEIU Brooklyn Cluster Friday, September 16 BC 9:00 am – 7:00 pm 25 Elm Place, Ground Floor Saturday, September 17 9:00 am – 4:00 pm Brooklyn, NY 11201 (212) 564-2220 Friday, October 14 9:00 am – 7:00 pm Subway: Saturday, October 15 9:00 am – 4:00 pm • Take the #2 or #3 train to Hoyt Street station • Take the A, B or F train to Jay Street station • Take the J, M, N, Q or R train to DeKalb Avenue station Site is located near the corner of Elm and Livingston Streets.

1199SEIU Future of America Learning Center (FALC) Saturday, September 24 FALC 10:00 am – 4:00 pm 2500 Creston Avenue, 3rd Floor Saturday, October 15 10:00 am – 4:00 pm Bronx, NY 10468 (718) 562-2915 Subway: • Take the D train to Fordham Road/Grand Concourse • Take the #4 train to Fordham Road/Jerome Avenue Site is located on corner of Grand Concourse/Fordham Road. NEW LOCATION: Friday, September 23 SI 9:00 am – 7:00 pm 1199SEIU Training and Employment Funds Saturday, September 24 9:00 am – 4:00 pm (Staten Island Office) 790 Port Richmond Avenue Friday, October 21 9:00 am – 7:00 pm Staten Island, NY 10302 Saturday, October 22 9:00 am – 4:00 pm (718) 448-7482 By Ferry (from South Ferry, St. George side): Take the S48 bus to Forest Avenue and Willowbrook Road or the S44 bus to Walker Street and Trantor Place. Walk to 790 Port Richmond Avenue. 1199SEIU White Plains Office Friday, September 23 WP 9:00 am – 7:00 pm 99 Church Street, 4th Floor Friday, October 7 9:00 am – 7:00 pm White Plains, NY 10601 (914) 997-2811 Travel Information: Call the 1199SEIU White Plains Office.

6 Locations and Directions Dates Calendar Code Times Capital Region (Albany) Friday, October 7 AO 9:00 am – 5:00 pm 1199SEIU Albany Office 155 Washington Avenue, Lobby One Albany, NY 12210 (518) 396-2300 Travel Information: Call the 1199SEIU Albany Office. Jack D. Weiler Hospital Friday, September 16 JW 9:00 am – 7:00 pm (Einstein Hospital/Albert Einstein College of Medicine) Wednesday, September 21 9:00 am – 7:00 pm 1825 Eastchester Road, Cafeteria Bronx, NY 10461 Wednesday, October 12 9:00 am – 7:00 pm (718) 904-2000 Friday, October 14 9:00 am – 7:00 pm Subway/Bus: Take the #5 train to Pelham Parkway station, then board the BX12 bus. Transfer at Eastchester Road for the BX31 bus to hospital. Jamaica Hospital Medical Center Friday, September 30 JH 8:30 am – 7:00 pm 89th Avenue and Van Wyck Expressway, Cafeteria Saturday, October 1 9:00 am – 4:00 pm Jamaica, NY 11418 (718) 206-6000 Friday, October 21 8:30 am – 7:00 pm Subway: Take the E train to Van Wyck station (take first Saturday, October 22 9:00 am – 4:00 pm subway car). Bus: Take the Q24, Q41, Q46 or Q54 bus to Jamaica Hospital. Maimonides Medical Center (the Union Office) Tuesday, September 27 MC 8:30 am – 5:30 pm 953 48th Street (corner of 10th Avenue), Basement Wednesday, September 28 8:30 am – 5:30 pm Brooklyn, NY 11219 (718) 283-6000 Subway: Take the D train to Fort Hamilton Parkway station (at 45th Street). Walk south on Parkway to 48th Street and turn on 10th Avenue. Registration site is located in basement. One Fordham Plaza Tuesday, September 13 FP 9:00 am – 7:00 pm Montefiore (Satellite) Wednesday, September 14 9:00 am – 7:00 pm 470 East Fordham Road, 6th Floor (State ID required) Bronx, NY 10458 Wednesday, October 5 9:00 am – 7:00 pm Subway/Bus: Thursday, October 6 9:00 am – 7:00 pm Take the D train to Fordham Road, then take the BX12 bus to Fordham University. Rochester Region 1199SEIU Rochester Office Thursday, September 15 RR 8:30 am – 7:30 pm 259 Monroe Avenue, Large Conference Room Strong Memorial Hospital Thursday, October 13 SH 7:00 am – 4:00 pm 601 Elmwood Avenue, South End of Cafeteria Friday, October 14 UR 8:30 am – 2:00 pm University of Rochester Medical Center 252 Elmwood Avenue, Wilson Commons 121

Travel Information: Call the 1199SEIU Rochester Office at (585) 244-0830. MidHudson Regional Hospital Monday, October 3 MH 9:00 am – 7:00 pm 241 North Road, Sister's Dining Room (Cafeteria) Tuesday, October 4 9:00 am – 12:00 pm Poughkeepsie, NY 12601 (845) 483-5000 and Travel Information: Call MidHudson Regional Hospital. 1:30 pm – 5:00 pm

7 Child Care Fund Introduction

The 1199SEIU/Employer Child Care Fund (CCF) was founded in 1992. Employers contribute to the CCF to provide 1199SEIU members with child-care benefits. The contribution is negotiated during collective bargaining and, as a result, the employer pays a percentage of gross payroll into the CCF. The CCF provides a variety of child-care benefits. They include after school care, day care, summer camp, cultural arts, holiday and teen programs. Members must meet certain eligibility requirements in order to apply for CCF benefits. Eligibility and Consideration for Benefits To apply for benefits, you must: • Be employed on a full-time or part-time basis (three-fifths [3/5] of a workweek) at a participating 1199SEIU institution or collective bargaining unit that contributes to the CCF; • Have passed the 90-day probationary period at your place of employment; • Have or be legally responsible for children between birth and 17 years of age (by birth or adoption); • Complete a program application before the deadline, provide proof of employment and child(ren)’s dependency, and supply all of the required documentation; • Have paid all previous co-payment balances and taxable CCF benefit costs; and • Not be on workers’ compensation or short-term disability for more than 26 weeks.

8 Required Documentation for Registration You must bring the following documents with your application in order to register:

First-time Applicants Returning Applicants Two (2) pay stubs are required. One (1) pay stub is required.

• All pay stubs must be dated within 30 days of registration. • If you do not have your pay stub(s), you must submit a letter from your employer verifying your employment, Social Security number, hourly pay rate, Pay Stubs date of hire and weekly work hours. • If you are on short-term disability or workers’ compensation, a copy of your last pay stub must accompany your disability stub. If the pay stub is not available, a letter from your employer verifying your employment, Social Security number, hourly pay rate, date of hire, weekly work hours and expected date of return must accompany your disability stub. A copy of the Social Security card of A copy of the Social Security card of each child for whom you are applying any child who was not registered for a is required. CCF program between 2000 and 2015 is • If you do not have a copy of your required. child’s Social Security card, you must provide the CCF with either of the following: Child(ren)'s Social »» An original letter from the Social Security Card(s) Security office showing your child’s Social Security number; or »» A copy of last year’s signed federal tax return showing your child’s Social Security number.

The CCF cannot register any child without a Social Security number/card, including newborn children who do not have one. There are no exceptions to this rule.

A copy of your 1199SEIU Health Benefits ID card, listing your dependent children, is required. • If your children are not listed on your 1199SEIU Health Benefits ID card, other acceptable proof of legal dependency is required, such as:

1199SEIU Health »» Adoption papers listing you as guardian; Benefits ID Card »» Birth certificate(s) listing you as parent; or »» A copy of last year’s signed federal tax return listing your adopted and/or biological child(ren). • If your bargaining unit does not contribute to the 1199SEIU Benefit and Pension Funds, you may submit your participating health insurance ID card, provided that your dependent children are listed on it. If not, you must provide proof of legal dependency, as listed above.

If you are missing any of the above documents, the CCF cannot register your child(ren).

9 Registering for CCF Programs Registration Period Registration for 2017 Child Care Fund benefits will begin Saturday, September 10, 2016, and continue through Monday, October 31, 2016. You can register in person or online. Online registration will start on Thursday, September 1, 2016, at 12:01 am and will end on Monday, October 31, 2016, at 11:59 pm. Please note that if you have any outstanding balances, you are not eligible to register for programs until your accounts have been paid in full. Applications mailed or faxed to the Child Care Funds will not be accepted. Registering in Person You must be sure to bring copies of all required documents as listed on page 9. We encourage you to register early to avoid long waits and possible delays in notification of benefits. Registering Online Over the years, the Child Care Funds have streamlined the online registration process for members. We have made the process simpler and faster so that you can register online in a few easy steps. The following “Important Online Registration Notice” provides helpful information about the online registration process:

Important Online Registration Notice

As of September 1, 2016, you can register online for 2017 child-care benefits. Visit www.1199SEIUBenefits.org/ccf to begin. Online registration is a secure process, which includes the following steps: 1) Entering information, adding programs and receiving a registration reference number 2) Submitting required documentation within one (1) week of registering online 3) Receiving confirmation from the CCF When you register online, you may: • Log in at any point during the registration period to add or change program priorities or selections; • Upload required documents; • Click the “Help” button for further assistance; and • View electronic versions of this Registration Information Booklet and the Service Provider Booklet (yellow booklet).

How Benefits Are Distributed The 1199SEIU Child Care Funds distributes benefits based on members’ benefit history and seniority. The benefit distribution process begins with members with no benefit history and continues through to members with benefit history until the budgeted monies are spent. Members acquire benefit history with the CCF once they utilize a CCF program. Members are grouped by the year in which they last received a benefit and then by their seniority within that group. Members with no benefit history (usually first-time applicants) are considered before those with benefit history. Finally,members with the most recent benefit history (2016) will be considered after everyone else. Notification of Benefit Distribution Results The CCF will inform you in writing of the results of the distribution by the end of December 2016. The CCF will mail a distribution packet to all members who receive a benefit. The packet contains a Program Status Letter along with next steps and related documents that must be returned in order to claim the benefit. The distribution packet will also be available online. Members will be able to log in to their account at www.1199SEIUBenefits.org/ccf and click on the “My Account” portal to access the Program Status Letter and related documents. If you have any questions, or if you have not received information about your benefit status by Friday, January6, 2017, you should contact the CCF promptly at (212) 564-2220.

10 Loss of Approved Benefits The following situations can result in a loss of benefit(s): • Terminations and Layoffs. All benefits will cease 30 days after the date of your termination or layoff. • Workers’ Compensation and Disability. Members receiving workers’ compensation or short-term disability will continue their benefits for up to a maximum of 26 weeks. After this point, all CCF benefits will immediately cease unless the member has returned to work. The CCF will require documentation from your employer confirming your return to work. • Failure to Make Applicable Co-payment(s) by the Deadline. In order to claim the benefit for which you were approved, you must submit all applicable co-payments by the indicated deadline. If you fail to make your co-payment, your approved benefit will be canceled. • Failure to Submit Required Reimbursement Forms. If you do not return the required reimbursement forms within 30 days of the due date, the approved reimbursement will be cancelled. • Position (Title) Changes. If you transfer to a non-Union position or to an 1199SEIU collective bargaining position that does not contribute to the Funds, your approved benefits will be cancelled within 30 days. • Employers’ Failure to Make Payments to the Funds. Members will receive a letter from the Greater New York Benefit Fund informing them of the termination date. All benefits will cease on the termination date indicated in the letter. If your employer makes the necessary payments before the termination date, your benefits will continue without interruption. Procedures Requiring Written Notification from the Member Dropping an Approved Program: • You must notify the CCF in writing in order to drop a program for which you have been approved. The CCF will not consider a program officially dropped until a written notice is received. Requests must be made four (4) weeks before a program starts. All summer day camp requests must be received no later than Friday, March 31, 2017. »» You are responsible for notifying both the provider and the CCF in writing should you decide to drop a program. If you fail to notify the CCF of your decision to drop a program within the designated time period, you will be held responsible for any co-payments due. »» If the CCF is not properly notified in writing of your decision within the designated time period, the program will still be reflected on your benefit history, and you will be placed at the bottom of the distribution list, by Union seniority, in the following year. Requesting Program Changes: • You must submit change requests to the CCF in writing. The CCF will not process the change request unless written notification is received. Requests for changes may also be emailed to [email protected]. Please include your full name and Member ID number. • Only one (1) program change is permitted. • For programs that require a co-payment, change requests will not be considered if the co-payment is not paid by the deadline. Please refer to page 12 for co-payment due dates. • Program changes are only available within the same program type. For example, you may be able to transfer from one summer day camp provider to another summer day camp provider. Changes between two different program types, for example, from a holiday program to a summer day camp, are not permitted. • Changes must be requested four (4) weeks prior to the start of the program or before the provider's stipulated withdrawal deadline; whichever comes first. • All program changes are subject to the availability of monies to accommodate the request. Change of Address: • You must notify the CCF directly. If your address changes, you must also send this information in writing to the 1199SEIU Benefit and Pension Funds and to the 1199SEIU Member Services Department. You can also change your address online through the “My Account” portal by visiting www.1199SEIUBenefits.org/ccf.

11 Change of Tax Status: • You must notify the CCF in writing. The CCF will not process your tax status change until written notice is received. • See Appendix A, page 21, the Tax Certification Worksheet for Dependent Care Expenses, to determine your tax status for each benefit selected. Change of Name: • The CCF will only process name changes made through the 1199SEIU Benefit and Pension Funds. The Funds’ policy is to use the name that appears on your 1199SEIU Health Benefits ID card. Payment Policy Co-payments If you are approved for a benefit that requires a co-payment, you must submit full payment with your Co-payment Invoice to the CCF.

Programs Requiring Co-payment Payment Options Important Notices Co-payment Deadline • Cultural Arts Program January 20, 2017 Online: Credit card and electronic check (Mosholu Montefiore • Electronic checks payments are only accepted online. Community Center and Hofstra University) • Credit/Debit cards • Make checks and money orders payable to “1199SEIU Child Care • Holiday Program (Winter) February 6, 2017 By Mail or In Person: Funds.” • Holiday Sleep-Away • Certified checks • Mailed payments must be Program (Winter) postmarked by the co-payment • Regular checks • SAT Prep deadline. • Money orders • Cultural Arts Program March 17, 2017 • Postdated checks are not (Harlem School of accepted. the Arts) • Returned checks are subject to a • Holiday Program (Spring) $25 fee. • Holiday Sleep-Away • Approved programs are dropped Program (Spring) if checks are returned and/or if full payment is not made by • Holiday Program the deadline. (December) • Summer Day Camp • Special Needs Summer Day Camp

You are encouraged to utilize the CCF’s easy and convenient Online Co-payment System (ePayments). You may make your co-payment from the comfort of your home by going to www.1199SEIUBenefits.org/ccf, logging in to “My Account,” selecting the “CCF Online” tab and clicking on “CCF Benefits Management” first and then clicking on “ePayments.” Making your co-payment online will allow the CCF to attempt to secure your child’s space at your selected program provider in a faster and more efficient manner. Refunds Co-payments are non-refundable once the CCF has either been billed by the service provider or has guaranteed payment to the service provider. If the CCF has not been billed or has not guaranteed payment, a co-payment refund may be possible.

12 Programs Choosing a Program that Is Right for Your Child The CCF does not license, recommend or endorse any particular provider. It is your responsibility to do the following: • Choose programs that meet the needs of your family and register for programs that you are certain your child(ren) will use; • Apply for more than one program, as you may not receive your first choice; and • Observe different programs and meet with providers to make informed decisions. Please see page 4 for a Program Selection Guide, which includes provider names, locations and payment guidelines. Multiple Benefits • When registering, consider the programs that are most important to your family and list your choices in priority order (1,2,3,…) on your application. • Priority numbers are required for each program you select. • If you are not approved for your first choice, it may be possible to receive your second choice. • If monies are available, you may receive more than one benefit.

There are no special exceptions made in the following cases: • In the case of multiple births during a single pregnancy, for example, twins. • If there are two (2) CCF-eligible parents in the same family working at the same or at different institutions, each parent may apply for the program(s) of his/her choice. However, the CCF will not approve duplicate benefits for the same child. • If you work at more than one (1) institution, you may submit only one (1) application, using either institution. • Unborn children do not qualify. The CCF only registers children between birth and 17 years of age. Special Needs The Child Care Funds work to ensure that children with special needs have access to all programs and services offered by the CCF. If you are approved for a benefit for a child with documented special needs, you must immediately notify the CCF Child Care Resource and Referral Services of the special services, programming or child-care arrangements needed. If you are currently using an unlicensed provider (i.e., friends, neighbors or relatives — with the exception of a spouse — who provide services) you may be eligible for the licensed provider (service provided by a person or a center licensed by or registered with the city, county or state) reimbursement rate to provide for your child’s special needs. In order to be considered for the higher, licensed provider rate of reimbursement, you must provide the CCF with the following: • A copy of your child’s Individualized Education Plan (IEP) indicating her/his diagnosis and recommended education plan; • A doctor’s note indicating diagnosis and treatment; and • A notarized letter from the caregiver/program indicating amount paid and special certifications/training of the caregiver. If you have questions or wish to submit documentation for approval, contact a CCF Program Services Counselor at (212) 564-2220. Children and Youth Programs/Services Offered by the CCF Child Care Resource and Referral (CCR&R) Services – Birth to 17 Years The Child Care Resource and Referral (CCR&R) Services team helps families take the guesswork out of finding child-care, summer camp and after school programs. The CCR&R team is committed to furnishing members with the most updated information and support for all their child-care needs. This information enables members to make the best choices from a variety of licensed or registered providers. Eligible members may call (212) 564-2220 for assistance.

13 Parenting Seminars Parenting seminars are theme-based and conducted throughout the year. They offer parents information and access to resources on a wide array of topics, ranging from child care to summer camp, to summer youth employment. College-based seminars encompass topics such as financial aid and how to successfully complete the entire college admission process. Other specialty topics range from special needs to SAT, to CSS profile workshops and college fairs. Experts in their respective fields conduct the seminars. The seminars are free; however, advance enrollment is required. For more information, visit www.1199SEIUBenefits.org/ccf. Institution and Volunteer Support – Advisory Committee The Child Care Funds Advisory Committee is comprised of 1199SEIU members from participating institutions who help to shape CCF programming. They do this by providing information and feedback on quality programs in various communities, and by acting as a liaison between institutions and the CCF. In addition to this vital role, members of the Advisory Committee volunteer their time at Fund-related events and assist with the registration process. Individuals interested in joining the Advisory Committee should call (212) 564-2220. Programs Year-Round Programs Child Care Learning Center (CCLC) | Future of America Learning Center (FALC) – 18 Months to 5 Years – Bronx Location Only The Child Care Funds (CCF) subsidize child-care slots at the 1199SEIU Child Care Corporation-sponsored early childhood education learning center. The Future of America Learning Center (FALC) is licensed by the New York City Department of Health and Mental Hygiene, and is accredited by the National Association for the Education of Young Children. Members' co-payment is based on a sliding fee scale. Acceptance is determined by the CCF's eligibility guidelines, availability of space and your child's age. Please note: If your child receives a subsidy for the Child Care Corporation-sponsored FALC, none of your dependents will be eligible for other programs for that year, except for the Holiday Programs. CCF trustees have established a maximum amount for all FALC subsidies. The CCF will notify you if you are projected to reach the maximum for the year. The FALC benefit cannot be transferred to any other program. This site is located in the Bronx. The FALC is a very costly benefit to the CCF. Members may also be eligible for the New York City Facilitated Enrollment Subsidy. If you are accepted for FALC, the CCF requires that you also apply for the Facilitated Enrollment Subsidy if eligibility permits. Your co-payment will be based on the lowest sliding scale fee for either CCF or Facilitated Enrollment. Co-payments are made directly to FALC. Free full-day (6 hours and 20 minutes) Pre-Kindergarten is available for eligible children. Extended services are also available.

Child Care Learning Center/Future of America Learning Center Sliding Fee Scale: Members’ Weekly Co-payment

Annual Salary 1 Dependent 2 Dependents 3 Dependents Up to $26,768 $78 $78 $78 $26,769 – $35,221 $99 $99 $99 $35,222 – $49,310 $113 $110 $106 $49,311 – $63,399 $127 $124 $120 $63,400 and above $155 $141 $134

14 Voucher Reimbursements

The voucher program reimburses you for the full or partial cost of your child-care expenses. Reimbursement is determined by a sliding fee scale based on your annual salary, number of dependents and type of care. The type of care utilized can be documented or undocumented. There are separate reimbursement scales for documented and undocumented care. • Documented care is service provided by a person or center (except the member’s spouse or the child’s parent) that is licensed by or registered with the city, county or state. • Undocumented care is service provided by a friend or relative (except the member’s spouse or the child’s parent) who is not licensed by or registered with the city, county or state. • Voucher reimbursements are paid quarterly and take approximately four (4) weeks to process from the deadline. • You must apply for the type of care (whether documented or undocumented) you are currently using. • If you change from undocumented to documented care during the benefit year, depending upon the availability of monies, you may receive the adjusted documented reimbursement rate. • Adjustment up to the documented rate can only be made upon receipt of the new provider’s license information and proof of payment. Members approved for an undocumented voucher for children with documented special needs (severe degrees of disabilities typified by autism, Down syndrome, spina bifida or other severe disabilities requiring a similar level of care) may receive a documented voucher. Submission of supporting documentation (page 13) is required upon program acceptance. After School Voucher (ASV) – 6 to 12 Years (Elementary School Children) – Various Locations The After School Voucher provides reimbursement for part-time child-care costs during the school year (40 weeks). • Vouchers can be used for after school or before school care. • Reimbursement flat rates are: $30 per week for documented care or $20 per week for undocumented care. • The third quarter consists of September only*, since school is not in session during the summer. For the third quarter, you will only receive a one-month reimbursement for the month of September.

After School Voucher (ASV-D) Quarterly Reimbursement Scale for DOCUMENTED Care

Maximum Annual Reimbursement First Quarter Second Quarter Third Quarter Fourth Quarter Jan. – Mar. Apr. – Jun. *Sept. Only Oct. – Dec. $30 x 40 Weeks = $1,200 $360 $360 $120 $360

After School Voucher (ASV-U) Quarterly Reimbursement Scale for UNDOCUMENTED Care

Maximum Annual Reimbursement First Quarter Second Quarter Third Quarter Fourth Quarter Jan. – Mar. Apr. – Jun. *Sept. Only Oct. – Dec. $20 x 40 Weeks = $800 $240 $240 $80 $240

15 Day Care Voucher (DCV) – Birth to 5 Years – Various Locations

The Day Care Voucher provides reimbursement for year-round, full-time day care or babysitting. Day Care Voucher (DCV-D) Quarterly Reimbursement Scale for DOCUMENTED Care

Annual Salary 1 Dependent 2 Dependents 3 Dependents 4 Dependents Up to $24,999 $780 $845 $910 $975 $25,000 – $34,999 $650 $715 $780 $845 $35,000 and above $520 $585 $650 $715

Day Care Voucher (DCV-U) Quarterly Reimbursement Scale for UNDOCUMENTED Care

Annual Salary 1 Dependent 2 Dependents 3 Dependents 4 Dependents Up to $24,999 $455 $520 $585 $650 $25,000 – $34,999 $325 $390 $455 $520 $35,000 and above $195 $260 $325 $390 WorkForce 2000 (WF2) – 14 to 17 Years Academic Enhancement and Youth Development Program Students must be attending high school as of September 2016 WorkForce 2000 (WF2) is a year-round academic program designed to help teenagers succeed in high school, prepare for college and explore career interests. Students participating in this program will work to develop helpful study strategies, writing skills and college action plans. Students will also receive targeted academic support and preparation for the PSAT, SAT or New York State Regents Exams. WorkForce 2000 Components for Program Year July 2017 – June 2018 1) Summer Experience (July 2017 through August 2017) • Summer Academic Experience: A four-week (4) program focused on enhancing academic skills, career exploration and college planning. • Summer Internship Experience (unpaid): Students meeting program requirements can apply for this six-week (6) summer internship to gain workplace experience and career exposure. 2) Saturday Academics (September 2017 through June 2018) • Students attend classes on select Saturdays at New York University. The school year component consists of educational classes, college and SAT preparation, life/leadership skills, social/cultural development and community building. 3) Pre-RN Track • Students accepted into WF2 who are considering a career in a nursing profession and who meet the Pre-RN Track's program requirements can apply for this year-round, career-focused academic and experiential program. 4) Workshops and leadership experiences are offered throughout the year, along with an annual Fall Retreat, which provides team building, skill building and problem solving opportunities. • All new students and their parents are required to attend orientation in winter 2017. • Students interested in pursuing a career in nursing can apply to the WF2 Pre-RN Track during orientation. There is no co-payment for this program. Please note that this program is taxable; member will receive a Form W-2 for this benefit.

16 Weekend Programs Cultural Arts Program (CAP) – 5 to 17 Years (Ages Vary by Provider) – Various Locations If you require child care in order to work weekends, your child(ren) may attend weekend classes during the school year. The Cultural Arts Program helps to cultivate creative thinkers and innovative leaders, and the CCF offers your child(ren) the opportunity to experience and explore high-quality cultural and academic enrichment programming at first-rate institutions in New York City and the surrounding metropolitan area. During the school year, youths will have the opportunity to participate in classes such as dance, music, theater, fitness, arts and crafts, and tutoring, which stimulates creativity and builds self-confidence. $100 co-payment is due Friday, January 20, 2017. Cultural Arts Stipend Program (CASP) – 5 to 17 Years – Various Locations This program is similar to the Cultural Arts Program, except that you must find your own provider who: • Has a tax identification number, established course descriptions and a fee schedule; • Has been in existence for more than two (2) years with an established arts, recreational or educational program; and • Offers age-appropriate programming to children ages 5 through 17. If all of the specified criteria are met, you may be reimbursed for the partial or total cost of the programup to a maximum of $700. You must provide the CCF with proof of your tuition payment and documentation that the program meets the listed requirements. If you need assistance finding CASP programs in your area, contact our CCR&R Services at (212) 564-2220. SAT Prep (SAT): ONLY for Students Who Are 11th Graders as of September 2016 Options for Prep Locations: Bronx, Brooklyn, Long Island, Manhattan or Queens This 21-week, Saturday morning SAT Prep program provides 11th graders with the proven skills and strategies needed to take the SAT exam. Students are also offered an extensive essay-writing workshop to help prepare for the college application writing requirement, and to receive guidance in the college application process. • Students must attend both sessions: »» Spring 2017: February/March through May (11th grade; junior year) »» Fall 2017: September through October (12th grade; senior year) • Parents and students are required to attend an orientation prior to the start of the program. $100 co-payment is due Friday, January 20, 2017. Please note that this program is taxable; member will receive a Form W-2 for this benefit. Holiday Programs Holiday Program (HP) – 3 to 15 Years (Ages Vary by Provider) – Various Locations This program provides child care during the weeks in February, April and December when children are on school breaks. The CCF contracts with conveniently located service providers for holiday camps throughout New York City and the surrounding metropolitan area. Check your Service Provider Booklet (yellow booklet) for more information. This program does not offer transportation and is scheduled according to the local public school calendar where the program is offered. $25 co-payment is due Friday, January 20, 2017. Holiday Sleep-Away Program (HSAP) – 8 to 17 Years (Ages Vary by Provider) – Various Locations The CCF provides the opportunity for your child to attend a five-day (5) and four-night (4) sleep-away camp program during the New York City public school winter and spring recesses. Campers participating in this program reside at an American Camp Association-accredited camp facility.

17 Program activities are age-appropriate and designed to engage children in music, sports, dance, nature hikes, and arts and crafts. Additional seasonally appropriate programming, such as snowshoeing and sledding, may be available. The Holiday Sleep-Away Program creates a safe, fun and educationally enriching experience for all participating children. They are encouraged to make new friends and are supported in their personal growth. This program offers round-trip transportation. Session Dates:

• Winter: Monday, February 20, 2017, through Friday, February 24, 2017 • Spring: Monday, April 10, 2017, through Friday, April 14, 2017 There is a co-payment based on the sliding fee scale below. Please note that this program is taxable; member will receive a Form W-2 for this benefit.

Holiday Sleep-Away Program (HSAP) Sliding Fee Scale

Annual Salary Co-payment Up to $24,999 $50 $25,000 – $29,999 $55 $30,000 – $34,999 $60 $35,000 – $39,999 $65 $40,000 – $44,999 $70 $45,000 and above $75

Summer Programs Summer Day Camp (SDC) – 3 to 17 Years (Ages Vary by Provider) – Various Locations The CCF contracts with summer day camp providers in New York City and the surrounding metropolitan area. The Service Provider Booklet (yellow booklet) lists camps that are close to your job or home. If available, the CCF will offer either transportation or extended hours (either AM or PM). This program offers day camp only, not sleep-away camp. Check registration sites in September and October for updates or changes to the Service Provider Booklet. Special Needs Summer Day Camp (SNSDC) – 3 to 17 Years (Ages Vary by Provider) – Various Locations In order to accommodate the many different documented special needs that children may have, the CCF contracts with summer day camp providers that provide special needs programs in New York City and the surrounding metropolitan area. Refer to page 13 to see if your child qualifies for special needs programs and to view required documents.

Sliding Fee Scale for Summer Day Camp (SDC) and Special Needs Summer Day Camp (SNSDC) Members’ Weekly Co-payment per Child

Annual Salary 1 Dependent 2 Dependents 3 Dependents 4 Dependents Up to $19,999 $10 $8 $6 $4 $20,000 – $24,999 $20 $15 $11 $8 $25,000 – $29,999 $30 $23 $17 $13 $30,000 – $34,999 $40 $30 $23 $17 $35,000 and above $50 $38 $28 $24

18 Summer Day Camp Voucher (SDCV) – 3 to 17 Years – For Day Camp Only – Various Locations Due to a limited number of camps listed outside of the New York City metropolitan area, a separate Summer Day Camp Voucher (SDCV) is available and is paid directly to the camp for residents of New Jersey, Connecticut, Pennsylvania, upstate New York and Long Island. This benefit will also apply to children who require special accommodations based on dietary or religious restrictions. • The CCF will only make payments to day camps that are licensed by or registered with the city, county or state. • On the application, indicate your reason for requesting the SDCV. • If you meet the established criteria, you may apply for a SDCV for a period of up to eight (8) weeks. • The SDCV may not be used for providers that have contracts with the CCF. The SDCV may not be used for sleep-away camp programs. There are no exceptions to this rule. Co-payments for summer programs are based on the sliding fee scale below.

Summer Day Camp Voucher (SDCV) Weekly Reimbursement Scale

1 Dependent 2 Dependents 3 Dependents 4 Dependents Annual Salary per Week per Week per Week per Week Up to $19,999 $190 $192 $194 $196 $20,000 – $24,999 $180 $185 $189 $192 $25,000 – $29,999 $170 $177 $183 $187 $30,000 – $34,999 $160 $170 $177 $183 $35,000 and above $150 $162 $172 $176

Special Needs Summer Day Camp Voucher (SNSDCV) – 3 to 17 Years – For Day Camp Only In order to accommodate the many different documented special needs that children may have, the CCF subsidizes summer day camp at the special needs site you select. • Refer to page 13 to see if your child qualifies for special needs programs and to see a list of required documents. • Indicate the name of the camp on your application. • Contact a CCR&R Counselor at (212) 564-2220 to assist you in your search for special needs summer day camp providers. • Reimbursement rates are based on a sliding fee scale that is applicable only after the required documents have been received and accepted. • If you meet the established criteria, you may apply for a SNSDCV for a period of up to eight (8) weeks.

19 Tax Liability As you may know, the Internal Revenue Service (IRS) considers some CCF benefits as taxable income. If your benefit is taxable, you will be responsible for paying the taxes due on the program in which your child participated. However, it has been the CCF’s experience that the majority of our members fall into the tax-exempt (tax-free) category. The following questions and answers may help to clarify your understanding of tax liability. Are some CCF benefits automatically taxable? Yes, based on IRS guidelines, all benefits for children who are 13 years of age or older at any point during a program are taxable. Also, Holiday Sleep-Away Programs are taxable regardless of the child’s age.

How do I know if the benefit is taxable?

Use the Tax Certification Worksheet for Dependent Care Expenses (Appendix A) to determine the tax status of each program for each child. For every benefit you are requesting, read the ten (10) statements on the Tax Certification Worksheet. If any of the statements applies to you, indicate “Yes” under the “Taxable?” column on the Program Selection Form section of the application. If none of the statements applies to you, indicate “No” under the “Taxable?” column on the Program Selection Form section of the application. If you need to make changes to the tax status of any program you receive, please indicate the change on your Co-payment Invoice and return the signed document to the CCF.

What do I do if the benefit is tax-exempt? For tax-exempt benefits, you will not have to pay any taxes unless the total cost of benefits received exceeds the IRS limits, which permits you to exclude the lesser of the following: • $5,000 for single or married filing jointly, and $2,500 for married filing separately; • Your earned income; or • Your spouse’s income, if you are married.

What do I do if the benefit is taxable? If your taxable benefit is adirect cash reimbursement (such as a Day Care Voucher, After School Voucher, Cultural Arts Stipend or Summer Day Camp Voucher), the CCF will deduct the taxes due directly from your payment. For example, if you receive a Day Care Voucher benefit, the CCF will: 1) Determine the amount of taxes due based on the Form W-4 Employee Withholding Allowance Certificate that you submitted during registration. 2) Deduct the taxes due. 3) Send you the balance of the voucher reimbursement. 4) Send you two (2) Form W-2s if you are approved for a taxable Day Care Voucher. The first W-2 will be issued by February 2018, indicating the amount that was reimbursed to you for the first, second and third quarters of 2017. The second W-2 will be issued by February 2019, for the fourth quarter that was paid to you in 2018. If your taxable benefit is an in-kind program benefit (such as WorkForce 2000, Summer Day Camp, Holiday Program, Holiday Sleep-Away Program, SAT Prep or Cultural Arts Program), the CCF will: 1) Determine the cost of your child-care benefit. 2) Determine and pay the payroll taxes associated with these program benefits. The CCF will pay both the employer’s and your share of FICA and Medicare taxes due. Your share of the taxes paid is considered to be an additional benefit paid for by the CCF. 3) Prepare and issue you a Form W-2 for the total value of the benefit at the end of the year. This will include the cost of the program, plus your share of payroll taxes that are paid by the CCF. The Form W-2 will also indicate any related income tax withholdings (i.e., federal, state and local) due on the value of your benefit that have already been paid by the CCF on your behalf. What if I am not sure whether or not the benefits are taxable? Be sure to consult your tax preparer or accountant to clarify any concerns that you may have.

20 Appendix A 1199SEIU Child Care Funds Tax Certification Worksheet for Dependent Care Expenses

In order for you to determine whether the benefit for which you are applying is taxable or not, you must certify to important information regarding the benefit, your child(ren) and employment status. Once accepted, you may change the tax status of the program if you believe it to be incorrect. Please read the information below carefully.

Eligibility Rule and Limitations For each program, read each of the ten (10) statements below. For each program for each child, if any of the ten (10) statements applies to you, indicate “Yes” under the “Taxable?” column on the Program Selection Form section of the application for Child Care Fund benefits. If none of the statements applies to you, indicate “No” under the “Taxable?” column on the Program Selection Form section of the application for Child Care Fund benefits.

1. Services are for the care of my dependent child, claimed on my tax return, who is q No q Yes 13 years of age or older at any point during the program.

2. Without adequate child-care services, I am still able to work. q No q Yes

3. All the children residing in my home are 13 years of age or older. q No q Yes

4. Reimbursement will be used to pay one of my children, who is under 19 years of age, q No q Yes for caring for his/her younger brother or sister. 5. I am paying for out-of-home care (family day care, camp, day care, etc.) that does not q No q Yes meet all of the licensing or registration requirements of state and local law. 6. My spouse is unemployed, is not looking for work, is not a full-time student and is capable q No q Yes of self-care.

7. My child spends less than eight (8) hours a day in my home (child does not reside with me). q No q Yes

8. My child plans to attend the CCF Holiday Sleep-Away Program. q No q Yes

9. My child plans to attend the SAT Prep Program. q No q Yes

10. My child plans to attend the WorkForce 2000 Program. q No q Yes

If you answered “Yes” to any of the above statements for a requested benefit, the benefit is considered taxable and you will be taxed on the value of the taxable child-care benefit received.

If you answered “No” to all of the above statements that apply to you for the benefit requested, the benefit is considered tax-exempt and you will not have to pay any taxes on the benefit. (Note: The same member could be taxed for WorkForce 2000 and tax-exempt for Summer Camp, so apply the test for each program.) However, if you are tax-exempt, there is a limit. The tax-exemption on this benefit permits you to exclude only the lesser of the following: • $5,000 for single or married filing jointly, and $2,500 for married filing separately; • Your earned income; or • Your spouse’s income, if you are married.

21 Appendix B

______

Waiver, Release and Certification __ DO NOT FAX OR MAIL CCF GNY ¨ In-house ¨ Field Parent Waiver ______Received by/Date I am the parent/guardian of the minor child(ren) as indicated on the 1199SEIU Child Care Fund (“CCF”) program application ______and I give permission for my child(ren) to participate in any CCF-sponsored program. Entered by/Date 2017 Program Application ______Edited by/Date I understand that while the CCF is providing payment or reimbursement for these programs, the CCF is not running the (Please Print Clearly in Blue or Black Ink) programs, but is contracting with different organizations (“providers”) that are running the programs. I acknowledge that the CCF assumes no responsibility whatsoever for the manner in which the programs are conducted, the Member Information activities that may be performed or any other matter related to or arising out of the programs. Therefore, in exchange Code Member’s full name: Jane______Doe for CCF payments for my child(ren)’s participation in the programs, I release and discharge the CCF and any of its First name Last name Trustees, officers, employees, affiliates, successors, assigns and agents (whether acting in their individual capacity 21______Park Avenue or as agents of the CCF) from any and all liability, responsibility or claims (including, but not limited to, claims for Address negligence) present and future, known or unknown, pertaining to any accident, injury, damage or loss to person or ______Brooklyn NY 11206 property which may occur during the course of my child(ren)’s participation in the programs. City State Zip [email protected] Preferred email Media Release [email protected] I hereby give permission for my child(ren) to be photographed and/or videotaped while participating in the programs www.1199SEIUBenefits.org/ccf Alternate email and agree that these photographs and/or video images may be used by the CCF, or by 1199SEIU United Healthcare ______(718) 555-1234 Workers East, or its related entities for promotional materials. Home phone ______(718) 555-4321 Tax Certification Cell phone ______I certify that I have read the Tax Certification Worksheet for Dependent Care Expenses and that these expenses for Member9876543210 ID # which programs or reimbursements are claimed will be incurred by me and are not payable by any other source. I further declare that I will not deduct these expenses on my federal, state or local income tax returns. I further certify Work and Family Information that if I selected “Yes” where applicable when asked “Taxable?” on the Program Selection Form section of the application, I am taxable for the CCF benefits and I understand that federal, state and local taxes will be withheld, ______Our Lady of Five Boroughs Nursing Home Code Employer and that a W-2 Form will be issued at year-end. Institution Radiology______Data Entry Clerk ______I certify that if I selected “No” where applicable when asked “Taxable?” on the Program Selection Form section of Department Position the application, I am seeking the CCF benefits to enable me to be gainfully employed and responsible for the care ______8:00 am 4:00 pm of my dependent(s) under the age of 13 and that the benefits are not payable from any other source. I further certify Union date of hire Work hours: from (AM/PM) to (AM/PM) that I have read and understood the eligibility rules and limitations set forth on the Tax Certification Worksheet for ______(212) 555-2345 239 ¨ Part time / ¨x Full time Dependent Care Expenses, that I meet the conditions for tax-exempt benefits and that I am eligible to receive tax- Work phone Ext. exempt benefits from the CCF. 6______2 4 $52,000 Family size: Number of adults Number of children Gross family income Member’s full name (please print): ______SAMPLEChild(ren)’s Information (only children under 18 years old) Signature: ______Date: ______SusanChild’s name Doe Child’sMelody name Doe 111-11-1111______222-22-2222 SSN # SSN # FOR OFFICE USE ONLY 11/4/13______Sex: ¨ M ¨ F 2______2/25/06 Sex: ¨ M ¨ F ______10 Date of birth x Age Date of birth x Age Document Checklist ______School type: ¨ Public ¨ Parochial ¨ Private ______5 School type: ¨ Public ¨ Parochial ¨ Private Grade Grade x Pay stubs: ¨ 1 ¨ 2 ¨ NBF Card ¨ W-4 Social Security card: ¨ Child 1 ¨ Child 2 ¨ Child 3 ¨ Child 4 ______RogerChild’s name Doe Child’sKeith name Doe ______

333-33-3333 444-44-4444 Alternative Documents SSN # SSN # ¨ Birth Certificate ¨ 1040 Tax Form ¨ Employer Letter ¨ V3 Screen Shot ______Sex: ¨ M ¨ F 13______Sex: ¨ M ¨ F ______16 6/25/03Date of birth x Age Date7/25/00 of birth x Age 8______School type: ¨x Public ¨ Parochial ¨ Private ______11 School type: ¨x Public ¨ Parochial ¨ Private

______full name Member’s Grade Grade

22 Your Guide to Selecting the Best Programs for Your Child Please refer to this guide when completing your program application. Instructions for Completing the Form Age Provider Name Number Co-payment or Please refer to the Registration Information Booklet and Service Provider Booklet. Program Name Program Description Range and Location of Weeks Reimbursement Priority: Using numbers (1, 2, 3…), list your program selections in order of importance. Priority numbers After School Voucher 6–12 yrs. Members are reimbursed a portion Documented: Licensed Provider 40 weeks Quarterly cannot be repeated. Documented (ASV-D) of after school program expenses. Undocumented: Unlicensed Provider School year: reimbursement; Undocumented (ASV-U) Sept. – June Doc. rate: $30/wk Child’s First Name: Print the first name of the child for whom you are requesting a program. Undoc. rate: $20/wk Child Care Learning 18 mos. – Early childhood center provides Future of America Learning Center 51 weeks Weekly co-payment Program Initials: Write only the program initials as they appear on the Program Selection Guide on the previous page. Center (CCLC) / 5 yrs. full day of age-appropriate learning 2500 Creston Avenue, Third Floor based on sliding fee Future of America activities and play. Bronx, NY 10468 scale. See scale on Provider’s Name: Write the name of the camp listed in the Service Provider Booklet or the full name of your child-care Learning Center (FALC) BRONX SITE ONLY (718) 562-2915 page 14. center or provider. For example, Fun Time Summer Camp, Five Boroughs Day Care Center or Sue Smith (babysitter). Cultural Arts Program 5–17 yrs. Weekend cultural and academic Select from Service Provider Booklet Varies Co-payment: $100 (CAP) programs are available for the (yellow booklet) Weeks: For Summer Day Camp only. Refer to the Service Provider Booklet for number of weeks offered by children of members who work the camp. Please note: the number of weeks may be subject to change. weekends. Various providers offer a variety of enriching classes in Hours of Care: For After School and Day Care Vouchers only. This refers to the time period your child is being recreational sports, academics, taken care of while you are at work. For example, after school/babysitter 3:00 pm to 6:00 pm, or day and visual and performing arts. care/babysitter 8:00 am to 6:00 pm. Cultural Arts Stipend 5–17 yrs. Weekend program for children of Member chooses provider. Varies Yearly Program (CASP) members who work weekends. See criteria listed on page 17. reimbursement; Extras: For Summer Day Camp only. Refer to the Service Provider Booklet and if offered, choose either $700 maximum transportation or extended hours AM or PM (1199SEIU Child Care Funds will only pay for one). amount Please note: The availability of transportation or extended hours is subject to change. Day Care Voucher Birth – Members are reimbursed a portion Documented: Licensed Provider 52 weeks Quarterly Reason: For Summer Day Camp Vouchers only, indicate the reason you are requesting a Summer Day Documented (DCV-D) 5 yrs. of day care program expenses. Undocumented: Unlicensed Provider reimbursement; Camp Voucher (based on location, religion or diet). Undocumented (DCV-U) See scale on page 16. Taxable: Some benefits may be taxable. To determine “Yes” or “No,” refer to the Tax Certification Worksheet SAT Prep (SAT) 11th Saturday morning classes designed Member selects preferred site: Bronx, 21-week Co-payment: $100 for Dependent Care Expenses in Appendix A of the Registration Information Booklet, located on graders to prepare 11th graders for all Brooklyn, Long Island, Manhattan program (both Benefit is taxable. page 21. Some benefits are automatically taxable, such as the Holiday Sleep-Away Program (HSAP), only aspects of the SAT exams. or Queens spring and fall SAT Prep (SAT) and WorkForce 2000 (WF2). sessions are required) Summer Day Camp 3–17 yrs. Licensed camps provide summer Select from Service Provider Booklet Varies Weekly co-payment; Program Selection Form (SDC) programs to children. (yellow booklet) See scale on page 18. Please refer to the Child Care Fund Program Selection Guide on the previous page. Special Needs 3–17 yrs. Special needs camps provide Member chooses provider. CCR&R can Varies Weekly co-payment; Child’s Program Provider’s Name Weeks Hours of Care (ASV, Taxable? Summer Day Camp programs to eligible children. assist in search. Call (212) 564-2220. See scale on page 18. Priority First Name Initials (SDC) DCV), Extras (SDC) or (SNSDC) Reason (SDCV) Summer Day Camp 3–17 yrs. Camps for those who live outside Member chooses provider. CCR&R can Up to a Weekly Voucher (SDCV) the New York City metropolitan assist in search. Call (212) 564-2220. maximum of reimbursement; ¨ No ¨ Yes area or who have dietary or 8 weeks See scale on page 19. ¨ No ¨ Yes religious restrictions. ¨ No ¨ Yes Special Needs 3–17 yrs. Special needs camps provide Member chooses provider. CCR&R can Up to a Contact CCR&R for Summer Day Camp programs to eligible children. assist in search. Call (212) 564-2220. maximum of reimbursement rates. ¨ No ¨ Yes Voucher (SNSDCV)SAMPLE8 weeks Call (212) 564-2220. ¨ No ¨ Yes WorkForce 2000 14–17 yrs., Teens prepare for college/careers Metropolitan Center for Research Year-round No co-payment (WF2) 8th–11th by participating in academic on Equity and the Transformation of program ¨ No ¨ Yes Benefit is taxable. graders sessions, workshops and unpaid Schools (Metro Center) ¨ No ¨ Yes internships, and are exposed New York University ¨ No ¨ Yes to cultural experiences and 726 Broadway, 5th Floor community service opportunities. New York, NY 10003

Holiday Program (HP) 3–15 yrs. Provides full-day camp services Select from Service Provider Booklet Winter, Co-payment: $25 Holiday Program / Holiday Sleep-Away Program for winter, spring and December (yellow booklet) spring and You may only select providers listed in the 2017 Service Provider Booklet. school breaks. December breaks Child’s First Name Provider’s Name Holiday Break for 2017 Taxable? (List in order of priority from 1–9) Holiday Sleep-Away 8–17 yrs. Participants attend a five-day Participants attend an American Camp Winter and Co-payment based Program (HSAP) (5) and four-night (4) sleep-away Association-accredited camp facility. spring breaks on sliding fee scale. Feb 2017 Apr 2017 Dec 2017 camp program. Program activities Facility has a heated living area, as well only; based See scale on page 18. ¨ No ¨ Yes include recreational sports, arts as indoor and outdoor program spaces on the NYC Benefit is taxable. ¨ No ¨ Yes and crafts, and nature activities. to ensure all participants have a safe, public school fun and educational experience. calendar ¨ No ¨ Yes

23 Your Guide to Selecting the Best Programs for Your Child Please refer to this guide when completing your program application. Instructions for Completing the Form Age Provider Name Number Co-payment or Please refer to the Registration Information Booklet and Service Provider Booklet. Program Name Program Description Range and Location of Weeks Reimbursement Priority: Using numbers (1, 2, 3…), list your program selections in order of importance. Priority numbers After School Voucher 6–12 yrs. Members are reimbursed a portion Documented: Licensed Provider 40 weeks Quarterly cannot be repeated. Documented (ASV-D) of after school program expenses. Undocumented: Unlicensed Provider School year: reimbursement; Undocumented (ASV-U) Sept. – June Doc. rate: $30/wk Child’s First Name: Print the first name of the child for whom you are requesting a program. Undoc. rate: $20/wk Child Care Learning 18 mos. – Early childhood center provides Future of America Learning Center 51 weeks Weekly co-payment Program Initials: Write only the program initials as they appear on the Program Selection Guide on the previous page. Center (CCLC) / 5 yrs. full day of age-appropriate learning 2500 Creston Avenue, Third Floor based on sliding fee Future of America activities and play. Bronx, NY 10468 scale. See scale on Provider’s Name: Write the name of the camp listed in the Service Provider Booklet or the full name of your child-care Learning Center (FALC) BRONX SITE ONLY (718) 562-2915 page 14. center or provider. For example, Fun Time Summer Camp, Five Boroughs Day Care Center or Sue Smith (babysitter). Cultural Arts Program 5–17 yrs. Weekend cultural and academic Select from Service Provider Booklet Varies Co-payment: $100 (CAP) programs are available for the (yellow booklet) Weeks: For Summer Day Camp only. Refer to the Service Provider Booklet for number of weeks offered by children of members who work the camp. Please note: the number of weeks may be subject to change. weekends. Various providers offer a variety of enriching classes in Hours of Care: For After School and Day Care Vouchers only. This refers to the time period your child is being recreational sports, academics, taken care of while you are at work. For example, after school/babysitter 3:00 pm to 6:00 pm, or day and visual and performing arts. care/babysitter 8:00 am to 6:00 pm. Cultural Arts Stipend 5–17 yrs. Weekend program for children of Member chooses provider. Varies Yearly Program (CASP) members who work weekends. See criteria listed on page 17. reimbursement; Extras: For Summer Day Camp only. Refer to the Service Provider Booklet and if offered, choose either $700 maximum transportation or extended hours AM or PM (1199SEIU Child Care Funds will only pay for one). amount Please note: The availability of transportation or extended hours is subject to change. Day Care Voucher Birth – Members are reimbursed a portion Documented: Licensed Provider 52 weeks Quarterly Reason: For Summer Day Camp Vouchers only, indicate the reason you are requesting a Summer Day Documented (DCV-D) 5 yrs. of day care program expenses. Undocumented: Unlicensed Provider reimbursement; Camp Voucher (based on location, religion or diet). Undocumented (DCV-U) See scale on page 16. Taxable: Some benefits may be taxable. To determine “Yes” or “No,” refer to the Tax Certification Worksheet SAT Prep (SAT) 11th Saturday morning classes designed Member selects preferred site: Bronx, 21-week Co-payment: $100 for Dependent Care Expenses in Appendix A of the Registration Information Booklet, located on graders to prepare 11th graders for all Brooklyn, Long Island, Manhattan program (both Benefit is taxable. page 21. Some benefits are automatically taxable, such as the Holiday Sleep-Away Program (HSAP), only aspects of the SAT exams. or Queens spring and fall SAT Prep (SAT) and WorkForce 2000 (WF2). sessions are required) Summer Day Camp 3–17 yrs. Licensed camps provide summer Select from Service Provider Booklet Varies Weekly co-payment; Program Selection Form (SDC) programs to children. (yellow booklet) See scale on page 18. Please refer to the Child Care Fund Program Selection Guide on the previous page. Special Needs 3–17 yrs. Special needs camps provide Member chooses provider. CCR&R can Varies Weekly co-payment; Child’s Program Provider’s Name Weeks Hours of Care (ASV, Taxable? Summer Day Camp programs to eligible children. assist in search. Call (212) 564-2220. See scale on page 18. Priority First Name Initials (SDC) DCV), Extras (SDC) or (SNSDC) Reason (SDCV) Summer Day Camp 3–17 yrs. Camps for those who live outside Member chooses provider. CCR&R can Up to a Weekly Voucher (SDCV) the New York City metropolitan assist in search. Call (212) 564-2220. maximum of reimbursement; 1 Susan DCV-D Five Boroughs Day Care 8:00 am - 6:00 pm ¨x No ¨ Yes area or who have dietary or 8 weeks See scale on page 19. 2 Melody SDC Fun Time Summer Camp 8 Transportation ¨ No ¨ Yes religious restrictions. x 3 SAMPLERoger CASP Seeking Provider ¨ No ¨x Yes Special Needs 3–17 yrs. Special needs camps provide Member chooses provider. CCR&R can Up to a Contact CCR&R for ¨ No ¨ Yes Summer Day Camp programs to eligible children. assist in search. Call (212) 564-2220. maximum of reimbursement rates. 4 Keith WF2 1199SEIU CCF x Voucher (SNSDCV) 8 weeks Call (212) 564-2220. ¨ No ¨ Yes WorkForce 2000 14–17 yrs., Teens prepare for college/careers Metropolitan Center for Research Year-round No co-payment (WF2) 8th–11th by participating in academic on Equity and the Transformation of program ¨ No ¨ Yes Benefit is taxable. graders sessions, workshops and unpaid Schools (Metro Center) ¨ No ¨ Yes internships, and are exposed New York University ¨ No ¨ Yes to cultural experiences and 726 Broadway, 5th Floor community service opportunities. New York, NY 10003

Holiday Program (HP) 3–15 yrs. Provides full-day camp services Select from Service Provider Booklet Winter, Co-payment: $25 Holiday Program / Holiday Sleep-Away Program for winter, spring and December (yellow booklet) spring and You may only select providers listed in the 2017 Service Provider Booklet. school breaks. December breaks Child’s First Name Provider’s Name Holiday Break for 2017 Taxable? (List in order of priority from 1–9) Holiday Sleep-Away 8–17 yrs. Participants attend a five-day Participants attend an American Camp Winter and Co-payment based Program (HSAP) (5) and four-night (4) sleep-away Association-accredited camp facility. spring breaks on sliding fee scale. Feb 2017 Apr 2017 Dec 2017 camp program. Program activities Facility has a heated living area, as well only; based See scale on page 18. Melody YMCA-HP 1 3 5 ¨x No ¨ Yes include recreational sports, arts as indoor and outdoor program spaces on the NYC Benefit is taxable. ¨ No ¨ Yes and crafts, and nature activities. to ensure all participants have a safe, public school Roger Sleep-Away Camp 2 4 x fun and educational experience. calendar ¨ No ¨ Yes

24 Waiver, Release and Certification

Parent Waiver I am the parent/guardian of the minor child(ren) as indicated on the 1199SEIU Child Care Fund (“CCF”) program application and I give permission for my child(ren) to participate in any CCF-sponsored program.

I understand that while the CCF is providing payment or reimbursement for these programs, the CCF is not running the programs, but is contracting with different organiations (“providers”) that are running the programs. I acknowledge that the CCF assumes no responsibility whatsoever for the manner in which the programs are conducted, the activities that may be performed or any other matter related to or arising out of the programs. Therefore, in exchange for CCF payments for my child(ren)s participation in the programs, I release and discharge the CCF and any of its Trustees, officers, employees, affiliates, successors, assigns and agents (whether acting in their individual capacity or as agents of the CCF) from any and all liability, responsibility or claims (including, but not limited to, claims for negligence) present and future, known or unknown, pertaining to any accident, inury, damage or loss to person or property which may occur during the course of my child(ren)s participation in the programs.

Media Release I hereby give permission for my child(ren) to be photographed and/or videotaped while participating in the programs and agree that these photographs and/or video images may be used by the CCF, or by 1199SEIU United Healthcare Workers East, or its related entities for promotional materials.

Tax Certification I certify that I have read the Tax Certification Worksheet for Dependent Care Expenses and that these expenses for which programs or reimbursements are claimed will be incurred by me and are not payable by any other source. I further declare that I will not deduct these expenses on my federal, state or local income tax returns. I further certify that if I selected “Yes” where applicable when asked “Taxable” on the Program Selection Form section of the application, I am taxable for the CCF benefits and I understand that federal, state and local taxes will be withheld, and that a W-2 Form will be issued at year-end.

I certify that if I selected “No” where applicable when asked “Taxable” on the Program Selection Form section of the application, I am seeking the CCF benefits to enable me to be gainfully employed and responsible for the care of my dependent(s) under the age of 13 and that the benefits are not payable from any other source. I further certify that I have read and understood the eligibility rules and limitations set forth on the Tax Certification Worksheet for Dependent Care Expenses, that I meet the conditions for tax-exempt benefits and that I am eligible to receive tax- exempt benefits from the CCF.

Members full name (please print): Signature:SAMPLE Date:

FOR OFFICE USE ONLY

Document Checklist Pay stubs: ¨ 1 ¨ 2 ¨ ealth Beneits ¨ W-4 Social Security card: ¨ Child 1 ¨ Child 2 ¨ Child 3 ¨ Child 4

Alternative Documents ¨ Birth Certificate ¨ 1040 Tax Form ¨ Employer Letter ¨ V3 Screen Shot

25 Appendix C

330 West 42nd Street, 18th Floor | New York, NY 10036-6977 | Telephone: (212) 564-2220 | Fax: (212) 629-8264

Program Status Letter / Tax Certification

JANE DOE 21 PARK AVENUE BROOKLYN, NY 11206

Congratulations! You have been accepted for the Child Care Fund benefit(s) below. Please follow the “Next Steps” and deadline(s) indicated.

MEMBER ID: 9876543210 BUDGET: 000001 Employer: Our Lady of Five Boroughs Nursing Home

Child’s Name: DOE, MELODY Accepted Program & Contact Information Weeks and Extras Co-Payment Deadline Taxable Summer Day Camp 8 Week(s) Payment Due: 3/17/17 No Amount: $102.00 Fun Time Summer Camp (718) 111-2222 Transportation www.FunTimeSummerCamp.org Est. Cost to Fund: $2,350.00

Next Steps - Summer Day Camp

Step 1: Make sure your packet contains the Co-Payment Invoice and a beige return envelope.

Step 2: Submit your co-payment by Friday, March 17, 2017

If you wish to make your co-payment by credit card or “eCheck,” visit www.1199SEIUBenefits.org/ccf, and log in to or sign up for “My Account.” Once you have logged in to “My Account,” select the “CCF Online” tab and click on “CCF Benefits Management” first and then click on “ePayments.”

You may also mail your payments to the Funds’ office. All checks and money orders must be payable to: 1199SEIU Child Care Funds. Mail payment to: 1199SEIU Child Care Funds, PO Box 837, New York, NY 10108-0837. Step 3: SAMPLEContact the provider immediately for enrollment and orientation information.

In the event that you would like to make a change or cancel your accepted program(s), please indicate the change, sign and mail your request to the address above to the attention of the 1199SEIU Child Care Funds. All requests are subject to management approval; you will be notified in writing of your status or adjustment(s). If you have been accepted for a program with a co-payment, remember to pay by the posted deadline in order to utilize your accepted program(s). Failure to do so may result in cancellation of your program(s).

As always, the Child Care Funds are pleased to assist you in meeting your child-care needs. If you have any questions relating to this Program Status Letter, please call us at (212) 564-2220 or email us at [email protected].

7/20/16

26 Notes ______

27 1199SEIU Child Care Funds 330 West 42nd Street, 18th Floor New York, NY 10036-6977 Tel.: (212) 564-2220 | Fax: (212) 629-8264 www.1199SEIUBenefits.org/ccf