Consolidated Appropriations Act of 2021

NOTE: This online application is for child care facilities located in PHILADELPHIA only. Providers in other counties should review the contact list on the PA Key website for directions on how to apply.
Coronavirus Response and Relief Supplemental Appropriation Act of 2021 (CRRSA) Child Care Provider Attestation Form

Instructions: Please complete and sign this Attestation form and submit it to the ELRC on or before April 21, 2021
Child Care Provider / Location Name *
Location MPI ID Number *
The MPI ID is located on the Certificate of Compliance issued by the Pennsylvania Department of Human Services (DHS) in the lower right corner above the Secretary's Signature.
Location Address *
Contact Information *
Method of Payment

If you have a current established payment method with the ELRC (such as Direct Deposit), the ELRC will maintain that process to issue this payment. If not, the ELRC may issue a paper check.
Payment Address
Enrollments *
ATTESTATION:
By submitting this form, I attest my DHS certified child care facility has been open since January 31, 2021 and is currently open and serving children. I attest the use of these funds will assist in maintaining child care operations and support costs or loss of revenue due to low enrollments, the purchase of cleaning supplies and/or services and personal protective equipment, staff supports, and any other necessary cost incurred to sustain business operations during the COVID-19 pandemic. I understand that I may be penalized by fine and/or referred to the Office of State Inspector General for criminal prosecution if I am suspected of engaging in fraud. The ELRC shall not be liable or bound in any manner by express or implied promises, statements, representations, or information. I understand information on this page may be relied upon to make payments from Federal funds, and any false information, statements, or documents or the concealment of material facts may be prosecuted under applicable Federal and State laws, including 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities.

All eligible providers may claim CRRSA funds by submitting this Attestation Form but providers who have not yet completed the Round 3/CARES Act reporting, funds will not be distributed until reporting is completed, or issues reconciled. If you need support completing this process, contact your ELRC.
Signature: *
Date: *

Month Day Year
Date
Print Name: *
Title: *
E-mail address for follow-up *
The funds issued are from the Coronavirus Response and Relief Supplemental Appropriation Act of 2021
Should be Empty:

NOTE: This online application is for child care facilities located in PHILADELPHIA only. Providers in other counties should review the contact list on the PA Key website for directions on how to apply.

Coronavirus Response and Relief Supplemental Appropriation Act of 2021 (CRRSA) Child Care Provider Attestation Form

Method of Payment

ATTESTATION: