Application For Child Care Subsidy Page 2

nyc

ACS

CS-925 (REVERSE)

REV. 5/07

NYC Administration for

Please complete income information for yourself AND anyone applying with you. See instructions for documentation requirements.

Children’s Services

(This includes children in need of care, their parents, step-parent and any other children under the age of 18 in household.)

PLEASE PRINT

GROSS

TYPE OF

OFFICE USE MONTHLY

ITEM

INCOME

DOCUMENTATION

CALCULATIONS

APPLICANT: Job earnings before deductions.

weekly

bi-weekly

semi-monthly

other

$

SPOUSE/OTHER PARENT: Job earnings before deductions.

weekly

bi-weekly

semi-monthly

other

FOR OFFICE USE ONLY

For all other income/ benefits please itemize below. Include the amount

INCOME

for yourself AND your spouse AND child(ren) who live with you.

DOCUMENTATION

CALCULATIONS

Alimony and/or child support. (Received)

weekly

bi-weekly

semi-monthly

other

Unemployment and/or worker’s compensation.

weekly

bi-weekly

semi-monthly

other

Net income from self-employment and/or rental income.

weekly

bi-weekly

semi-monthly

other

BENEFITS: Social Security, SSI, Disability, Retirement and/or Pensions & Annuities.

weekly

bi-weekly

semi-monthly

other

OTHER INCOME/BENEFITS

(Check All That Apply) :

Cash or monetary assistance through the Temporary Assistance to Needy Families (TANF) program or Public Assistance (PA).

Housing voucher or cash assistance.

Food stamps.

Other federal cash income programs (such as SSI).

TOTAL INCOME:

$

If your child is already in care, or you know the name of the program/provider where you plan to enroll your child, please list the provider name and address below.You may list a second choice.

Name: _____________________________

Name: _____________________________

Name: _____________________________

PROGRAM #

PROGRAM #

PROGRAM #

Address: ___________________________

Address: ___________________________

Address: ___________________________

Please check the types of care that you would consider if there are no available slots with the provider(s) you listed above or if you do not have a provider in mind:

Center Based Care

Head Start

Informal Care

Family Day Care

Is/are the child/children for whom you are applying a U.S. citizen(s)?

YES

NO

If Yes, Parent/Guardian must sign and date to certify that the child/children in receipt of child care assistance/subsidy _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ______ /______ /______

a U.S. citizen(s).

is/are

PARENT/CARETAKER/WIFE/HUSBAND

DATE

If No, your eligibility must be determined at the Resource Area (R.A.), please make an appointment at your R.A. and bring the documentation listed in the instructions for this form.

1. I understand that the information contained on this form will be used to determine my or

York State Law and Federal Law provides that any applicant may be investigated for

my family’s eligibility for services/subsidy and that the information will only be used for

fine or jail or both, for a person found guilty of obtaining child care assistance/subsidy

the purposes of determining child care eligibility.

by concealing information or providing false information.

2. The social security numbers (if provided) will not be released as they are confidential under

4. I understand that this application is used only for the expressed purpose of child care

federal law and can be released/used only for the purposes specified in federal law.

subsidy. To obtain other assistance such as Food Stamps, Medicaid, Temporary

Assistance, or other services, additional applications will be required.

3. I agree to inform the agency immediately of any change in my income, living

arrangement, household composition or address, where care is provided, who is

5. I certify under the penalty of law that all the information I have supplied on this form is

providing child care, provider fees, hours for which child care is needed, and that New

true and correct.

Please provide the signature of the parent/caretaker who is applying for child care assistance or the signature of an authorized representative.

X

X

__________________________________________________

______ /______ /______

__________________________________________________

______ /______ /______

SIGNATURE PARENT/CARETAKER/WIFE/HUSBAND

DATE

SIGNATURE AUTHORIZED REPRESENTATIVE

DATE

___________________________________________________________________________

______________________________________________________________________________

PRINT NAME

PRINT NAME

Enrollment Application Completed by: __________________________ ______ ______ /______ /______

Length of Eligibility:

from: ______ /______ /______

PRINT AND INITIAL

DATE

to: ______ /______ /______

ACS – Eligibility Approved by: ________________________________ ______ ______ /______ /______

I.S. – Verified by: _______________ ______ /______ /______

PRINT AND INITIAL

DATE

Parent Fee:

______ ______ /______ /______

PRINT AND INITIAL

DATE

INITIAL

DATE

CODES: RFC: _____ PR: _____ FS: _____