SCHOOL READINESS PROGRAM
CLIENT REQUEST TO FILE AN APPEAL
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ELCNC USE ONLY
Mailed
Faxed
In Person
Drop Box
Initials
School Readiness clients have the right to appeal eligibility decisions made by the ELC. To file an appeal, please indicate the eligibility decision you are appealing
sign and date the form, attach appropriate documentation, and submit the documents to your local ELC office.
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Cancellation of School Readiness services due to the failure to meet one or more eligibility requirements.
Cancellation of School Readiness services due to the failure to respond to an ELC request for required program documents. Attach proof of the extenuating
circumstances that prevented you from submitting required program documents by the stated due date and attach the required program documents.
Cancellation of School Readiness services due to suspected fraud.
Cancellation of School Readiness services due to the extended absence of a child (five (5) or more consecutive days) without contacting the Early Learning
Provider. Attach proof of the extenuating event that prevented you from contacting the Early Learning Provider during your child’s extended absence.
Suspension of School Readiness services due to the failure to report changes in your household within ten (10) calendar days of the change. Attach proof of the
extenuating circumstances that prevented you from notifying the ELC of changes in your household within the required timeframe.
Suspension of School Readiness services due to the failure to pay the assessed copayment. Attach copies of copayment receipts.
Suspension of School Readiness services due to the failure to sign your child or children in and/or out of the program.
Other: _____________________________________________________________________
Describe your grounds for disputing an ELC decision and attach documentation to support your position: _______________________________________________
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Attach an additional page if more space is needed.
I understand that the ELC will process my appeal within ten (10) calendar days of receipt and that I will receive a copy of this completed form which will indicate the
appeal decision. In the event the appeal is denied, I understand that within ten (10) calendar days of the appeal decision I have the right to request another review of
my appeal which will conducted by the Executive Committee of the ELC Board. I understand that more information about the appeals process is provided in ELPOP
400.03: School Readiness Program Parent Handbook, which is available at www.elc-naturecoast.org.
Printed Applicant Name: _____________________________________ Applicant Signature: ___________________________________ Date: _________________
FOR ELC USE ONLY
REQUEST FOR APPEAL DECISION: Note: Appeals related to the suspension of School Readiness services may only be approved or denied; whereas, appeals
related to the cancellation of School Readiness services may be approved, approved with a suspension in services, or denied.
Is the client eligible to receive School Readiness services if the appeal is approved? Yes
No
If this request is related to an ELCNC decision that was made as a result of suspected fraud, the request must be referred to the Finance Manager.
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APPROVED: Client must be eligible for School Readiness services and one or more of the following must apply:
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Client submitted documentation of the extenuating circumstance that prevented the client from adhering to program participation requirements.
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The eligibility decision resulting in the suspension or cancellation of School Readiness services was made in error.
APPROVED WITH SUSPENSION: All of the following apply:
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Appeal is related to the cancellation of School Readiness services.
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Client is eligible for School Readiness services.
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Client failed to provide proof of extenuating circumstances that prevented the client from adhering to program participation requirements.
Suspension Applied:
First offense: Thirty (30) calendar day suspension.
Second offense: Sixty (60) calendar day suspension.
Three or more offenses: Ninety (90) calendar day suspension.
DENIED: The appeal is denied for one or more of the following:
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The client is not eligible for School Readiness services.
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The client failed to document the extenuating circumstances that prevented the client from adhering to program participation requirements,
which resulted in the suspension of School Readiness Services.
Program Manager Signature: _______________________________________________________
Chiefland Office
117 NE 1st St
Chiefland, FL 32626
352-490-5855 Phone
352-490-6762 Fax
877-840-5437 Toll-Free
Crystal River Office
382 N Suncoast Blvd
Crystal River, FL 34429
352-563-9939 Phone
352-563-5933 Fax
877-336-5437 Toll-Free
Sumterville Office
617 S US Hwy 301
Suite E
Sumterville, FL 33585
352-793-5430 Phone
352-793-6230 Fax
Date: ____________________________
ELPOP 400.18: Client Request to File an Appeal