Child Care Subsidy: How to Submit an EBT-4

The EBT-4 form is used to make adjustments to providers when incorrect case information is transmitted to EPPIC and the provider is paid incorrectly. Refer to Article Child Care Subsidy: When to Submit an EBT-4 for additional information on determining when to submit an EBT-4. Form 10EB004E, EBT-4 is located on the Forms page on the InfoNet.

Use the following instructions to complete an EBT-4 form.

Note: When entering information into the EBT-4 form, ONLY enter what the correct information should have been.

  1. Provider Information:
    • Enter Child Care Provider Name
    • Enter Contract Number

    EBT-4 form

  2. Client Information:
    • Enter the Case Number
    • Enter the Case Name
    • Enter the Month and Year in which the correction is needed.

    Reason(s) for Manual Payment Adjustment Submission.

        1. Incorrect co-payment.

          If the EBT-4 is necessary because of an incorrect unit type or incorrect number of units:

          • Click in the box beside Incorrect co-payment
          • Enter ONLY the correct co-payment amount. (the amount the co-payment should have been).
        2. Incorrect unit type or number of units
          EBT-4 form - Incorrect unit type or number of units
          If the EBT-4 is necessary because of an incorrect unit type or incorrect number of units:

          • Click in the box beside incorrect unit type or number of units. This will cause a chart to appear which you will use to enter the correct Unit type / Number of Units for all applicable children. You should notice red boxes to the left and green boxes to the right of the chart. Click on any green + box to add lines for any additional children. Click on any red – box to delete any lines that are not necessary for the EBT-4 form.
          • Enter Person Number of child as a two digit number. 03 for example

          Unit Type (K55) /  Number of Units (K50)  –  PRIMARY AUTHORIZATIONS ONLY

          • Enter ONLY the correct Unit Type (K55) if a correction is needed for the Unit Type (Click the drop down arrow and select the correct Unit Type)
          • Enter ONLY the correct Number of Units  (K50) if a correction is needed for the Number of  Units (Click the drop down arrow and select the correct Number of Units)

          Unit Type (K68) / Number of Units (K67) – SECONDARY AUTHORIZATIONS ONLY

          • Only Use K68/K67 fields if a correction is needed for Secondary Authorizations.
        3. Incorrect star statusIf the EBT-4 is necessary because of an incorrect STAR STATUS:
          • Click in the box beside Incorrect star status
          • Click the drop down arrow and select the correct star status
        4. Incorrect date of birthIf the EBT-4 is necessary because of an incorrect date of birth:
          • Click the box beside Incorrect date of birth
          • Enter Person number of Child.
          • Enter Date of birth in MM/DD/YYYY format
        5. Pending swipes over 90 days old.
          Option 5 is only used for pending swipes that have not been paid and are over 90 days old.
          EBT-4 form, Pending swipes over 90 days old is checked.

          • Remember that all pending swipes that are less than 90 days old will be paid automatically by the EPPIC system once the worker makes the necessary corrections in FACS.
          • For any swipes that have been DENIED and need to be paid, the provider must submit a manual claim. (An EBT-4 form is not used for denied swipes).
            • Click on the Box next to Pending swipes over 90 days old. This will cause a chart to appear which you will use to enter authorization Number and For Date.
            • Enter the Authorization Number. Refer to article Child Care Subsidy: EKL Screen on how to obtain authorization number.
            • Click on the For Date field, Click on the drop down arrow, and click on the calendar date in which payment is needed.

    Use the Comments Box to enter any additional information that is pertinent to the case regarding Child Care Payment Adjustments for the Specific Month.

    Person Competing Form:

        • Enter First Name of Person completing form
        • Enter Last Name of Person completing form
        • Enter the Supervisor #
        • Enter the Worker #
        • Enter phone number with area code
        • Enter date in MM/DD/YYYY format
        • Click drop down arrow and select County
        • Click Submit

    REMEMBER: One form must be completed for each month payment adjustment is needed.

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