Cs-925 Form - Application For Child Care Subsidy

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nyc
CS-925 (FACE)
NEW
ACS
REV. 5/07
APPLICATION FOR CHILD CARE SUBSIDY
RECERTIFICATION
NYC Administration for
Children’s Services
TRANSITIONAL CHILD CARE
PLEASE PRINT IN ALL CAPITAL LETTERS
Case #:
OFFICE USE ONLY
Application Date: ______ /______ /______
LAST Name (Please include any aliases or maiden names in parentheses) :
FIRST Name:
M.I.:
ADDRESS Residence:
APT. #:
CITY/BOROUGH:
STATE:
ZIP CODE:
ADDRESS Mailing (if different than above) :
APT. #:
CITY/BOROUGH:
STATE:
ZIP CODE:
TELEPHONE (Work) :
TELEPHONE (Home):
TELEPHONE (Cell or Other) :
(
) ____________________________________________
(
) ____________________________________________
(
) ____________________________________________
Do you receive PA?
YES
NO
Do you receive Medicaid?
YES
NO
What is your primary language?
PA #: __________________________________________
MA #: __________________________________________
Please fill out the information below for your entire household. List yourself first, followed by everyone who lives with you.
DOES THIS
BOTH OF CHILD’S
HISPANIC
RACE
SOCIAL
LAST Name
DATE OF
SEX
PERSON NEED
PARENTS RESIDE
OR
(SEE
SECURITY
FIRST Name M.I.
RELATIONSHIP
BIRTH
(PLEASE INCLUDE ANY ALIASES OR
M/F
CHILD CARE?
IN THE HOME?
LATINO
LEGEND
NUMBER
MM/DD/YY
MAIDEN NAMES IN PARENTHESES)
YES/NO
YES/NO
YES/NO
BELOW)
(OPTIONAL)
1.
SELF
2.
3.
4.
5.
6.
RACE: 1.Native American or Alaskan Native
2. Asian
3. African American/ Black
4. Native Hawaiian/Pacific Islander
5. Caucasian/ White
For additional family members, please attach a separate sheet.
OFFICE USE ONLY
Include information for any spouse/other parent of the children applying for care who lives in the home.
Family Size: ______
APPLICANTʼS EMPLOYER Name:
Hours per week:
Tel #:
(
) ______________________________
ADDRESS:
CITY/BOROUGH:
STATE:
ZIP CODE:
APPLICANTʼS Scheduled Days and Hours of Employment (i.e.: Mon – Fri, 9 a.m. – 5 p.m.) :
Does Job have a Rotation Shift?
YES
NO
Does Job Require O/T?
YES
NO
SPOUSE/OTHER PARENT EMPLOYER Name:
Hours per week:
Tel #:
(
) ______________________________
ADDRESS:
CITY/BOROUGH:
STATE:
ZIP CODE:
SPOUSE/OTHER PARENT Scheduled Days and Hours of Employment (i.e.: Mon – Fri, 9 a.m. – 5 p.m.) :
Does Job have a Rotation Shift?
YES
NO
Does Job Require O/T?
YES
NO
Are you requesting child care primarily so that you can work?
YES
NO
Is the child for whom you are requesting care living with
someone other than his/her mother or father?
YES
NO
If not, please read the instruction section titled “Child/Family Needs” and write your
Does your child have any conditions that require special help or
reason for care here:
attention?
YES
NO
___________________________________________________________________________
Does your child have health insurance?
YES
NO
OVER

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