SAMPLE ONLY
*Co-Payment Agreement
Child Care Scholarship Program
All scholarships will have
$0.00*
for the Assigned Co-payment amount. To determine the copay per scholarship, complete the following:
1. The parent must complete each question on this chart;
2. For any question answered “yes”, the parent must show proof to the child care program in order to receive a $0.00 Assigned Co-
payment per week;
3. Both the parent and the child care program must complete and sign the bottom of the Co-Payment Agreement; and
4. The child care provider must return the completed form to CCS Central 2 by email at CCSScholarships@maryland.gov
My Status or child’s status Yes or No Action Required
Assigned Co-payment per week*
(If you answered yes & provided proof)
Go to Question 7, Section 3 of the
CCS Application. If you answered
“Yes” to any of those questions,
mark “Yes” for this question**
Yes
No
Show proof to your child care program. $0.00
Receives Federal Housing Act
Housing Choice Voucher Program**
Yes
No
Show proof to your child care program. $0.00
Receives Federal Supplemental
Nutrition Assistance
Program (SNAP)**
Yes
No
Show document to child care program. $0.00
My household receives Supplemental
Security Income (SSI) benefits**
Yes
No
Show document to child care program. $0.00
Receives Temporary Cash
Assistance (TCA)?**
Yes
No
Show document to child care program. $0.00
I am a Migrant Worker or the
other adult in my household
is a Migrant Worker**
Yes
No
Show proof to your child care program. $0.00
I am a Minor Parent with a
child who needs child care**
Yes
No
Show proof to your child care program. $0.00
My household participates in the
Montgomery County Guaranteed
Basic Income (GBI) Program**
Yes
No
Show proof to your child care program. $0.00
My household receives Federal
Special Supplemental Food
Program for Women, Infants
& Children & (WIC)**
Yes
No
Show proof to your child care program. $0.00
My household receives a Welfare
Avoidance Grant (WAG)**
Yes
No
Show proof to your child care program. $0.00
A child in my household count
is enrolled in Head Start or
State Funded Pre-K**
Yes
No
Show proof to your child care program. $0.00
Does any of the above apply
to my household**
Yes
No
Pay Assigned Co-payment directly
to your child care provider.
$3.00 per week - 3 unit scholarship
$2.00 per week - 2 unit scholarship
$1.00 per week - 1 unit scholarship
**Note: If you answered “yes” to any of the above, but you cannot or decided not to show proof of receipt or enrollment to your
child care program, your assigned co-payment per scholarship will be based upon the Unit of Care authorized on each scholarship
($1.00 - $3.00 per week per child).
If the total of the child care scholarship and the Assigned Co-payment does not cover the child care program’s weekly tuition, the parent is
responsible for paying the difference owed to the child care program in addition to the weekly Assigned Co-payment.
We acknowledge that parents participating in the above programs and who have shown proof to their child care provider are eligible for
a $0.00 Assigned Co-payment per week. All other families must pay an Assigned Co-payment per week that is equal to the Unit of Care
authorized each Child Care Scholarship. Child care providers must email a completed Co-Payment Agreement for each child with a
scholarship to CCS Central 2. Effective May 23, 2022, child care providers must email both the completed Child Care Scholarship
and the completed Co-Payment Agreement to CCSScholarships@maryland.gov
Parent Signature
V
ouche
r
Number Date Provider Signature Provider ID
D
ate
DOC.922.01 Revised 05/2022
