Parent/applicant Worksheet (Child Care And Development Fund Voucher Program)
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Parent/ Applicant Worksheet (Child Care and Development Fund Voucher Program)
(V4-16)
Parent Name
AIS Case Number
Parent Date of Birth
Home Phone, including area code
Other Phone, contact number:
Street Address
City
Zip
County
Is this a new address?
Mailing Street Address, if any
Mailing Address City, if any
Mailing Address Zip
Primary Language Spoken in the Home
List adults in household:
Birth Date:
Specify
Working
School
Highest grade
Hours
Hours needed
Hours needed
Days per week
First Name, Last Name
Relationship
Yes or No
Yes or No
completed
working or in
for travel per
for study per
care is needed
to Parent:
school per
week
week
S, M, Tu, W, Th, F, S
week
SELF
List your children living in household
Birth Date
Relationship to
Check if child
Indicate which parent(s)
Earliest Drop-off
Latest Pick-up
Is there a different
First Name, Last Name
Parent/Applicant
needs care
are living in household
child care provider?
Indicate AM or PM
Indicate AM or PM
Yes or No
□ Mother □ Father
□
□ Mother □ Father
□
□ Mother □ Father
□
□ Mother □ Father
□
□ Mother □ Father
□
□ Mother □ Father
□
INCOME DISCLOSURE (Include all income received in previous 30 days)
PLEASE ANSWER THE FOLLOWING QUESTIONS:
Income Source
Monthly Amount
For Whom
Verification must be attached
Completed Child Support
1. In what school district do you live? _______________________________
Child Support
Declaration form provided
2. Are you living in a homeless shelter or domestic violence shelter?
Award letter, check stub, or
YES
NO
Social Security
verification from agency
3. Are you living in your car, a park, or other public place?
Supplemental Social
Award letter, check stub, or
Security
verification from agency
YES
NO
Award letter, check stub, or
4. Are you living in a residence with family and/or friends?
TANF
verification from agency
YES
NO
Uplink Claimant Homepage or
5. Where is your family living? _____________________________________
Unemployment
verification from agency
6. Are any children on your application disabled?
Pay stub, or Cancelled Check
Wages, Salary
(front and back) and Wage Detail
YES
NO
Form
7. Are you or your co-applicant active in the US Military, National Guard of
Reserve?
Housing Assistance
None
YES
NO
8. Do you have assets which exceed one (1) million dollars?
Food Stamps
None
YES
NO
Work Study
None
9.
Would you like to receive any additional information about other types of
Attach appropriate
assistance programs in your area?
YES
NO If yes, please indicate
Other
documentation
program(s) of interest below.
ATTENTION! Failure to attach ALL required documentation will result in
___________________________________________________________
termination of child care benefits without notice. (Please use application checklist
provided to assist in preparation of worksheet for mailing.)
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