An Application Packet (Page 2 of 14) in pdf

YOUR CHECKLIST

(For Eligibility Determination)

Please use this checklist to help you complete the application package. We must have documentation of all household income. All of this information may be

mailed or faxed to Workforce Solutions Northeast Texas Child Care Services. You may go to your nearest Workforce Solutions Northeast Texas center to use a

computer, printer or fax machine free of charge. Visit for the location nearest you. For child care assistance call: (903)794-8999 or (800)

874-3226.

IF YOU OR YOUR SPOUSE (Or Other Parent in Home) WORK…

FORMS ALL FAMILIES NEED TO RETURN:

Employment Verification Form (1 page)

Child Care Assistance Eligibility Certification Form (2 pages)



Ask your supervisor to fill out the form, sign and date it.

Please fill out the form by completing ALL information requested, sign it

and return to us.

Income Verification Documents:

Customer Awareness Form (1 page)



We must have a copy of your last three check stubs for each job held by an adult



in the family. The check stubs MUST have the family member’s name on it, no

Please read the form, initial and sign. Return it to us. Keep one copy of it

for your interview with us when you call

exceptions! If check stubs are not available, copies of checks with wage and

hours are acceptable.

Parent Acknowledgement Form (2 pages)

“What if I started a new job or I’m paid in cash and do not have a



Please read the form, sign it and make a copy of it for your records and

check stub?”

return to us

If you are paid in cash, you are considered Self Employed and you must follow

the instructions in the following paragraph. If you’ve started a new job and

Parent Responsibility Agreement Parent Self-Declaration of

haven’t received your first paycheck yet, the Employment Verification Form is

Compliance

acceptable. In three months, check stubs or a copy of checks with gross wage



and hours listed will be required

Please read the form, mark appropriate answer, sign and date. Return

“What if I’m self-employed and do not have a check stub?”

the form to us.

If you are self-employed and do not have a check stub, we must have a copy of

Parent Automated Attendance Card Agreement

one of the following: your latest 1040, Schedule C, F, or SE Tax Return – OR –



Proof of income and expenditures (copies of money orders or checks received

Please read the form, sign and date. Return the form to us.

and lists of individuals/customers served or personal wage records with third

party signed verification) with one of the following: Property title, Deeds, Rental

Attorney General Compliance and documentation of Child

Agreement for the place of business, Recent business bank, phone, utility, or

Support Income

insurance bill, Business records that provide proof of income and expenditures,



You must provide one of the following for each non custodial parent:

or Business plans.

▪

If you are complying with the Attorney General’s office, we must

IF YOU OR YOUR SPOUSE (Or Other Parent in Home) GO TO

SCHOOL OR ATTEND A TRAINING PROGRAM…

have documentation of compliance along with a printout of payments

from the AG’s office.

▪

Training Verification Form (1 page)

If you are receiving Child Support through a private agency or



another state, we must have a printout from that agency that shows a

Ask your school/training institution to fill out the form, sign and date it.

current child support payment history for each child.

Training Verification Documents

▪

If you have an informal Child Support arrangement, submit



documentation of what is received and a 3 month history of payments. This

For college students, we must have a copy of your most recent transcript

and your current class schedule.

must be signed by both the custodial and non-custodial parent. Again, each

non-custodial parent must sign and document the payment history. The non-

custodial parent’s signature must be notarized.

Return all forms to Workforce Solutions Northeast Texas:

Additional information for AG Compliance can be found on the enclosed

Fax all requested documentation to (903) 794-8012 or (877) 329-6772;

“Required Documentation of Child Support.”

or you may

Mail all requested documentation to: Workforce Solutions Northeast Texas, Attn: Child

A copy of a birth certificate for all children under 13 years of age.

Care Services, 1702 Hampton Rd, Texarkana, TX 75503

INCOMPLETE PAPERWORK MAY RESULT IN YOUR CHILD CARE SERVICES BEING DENIED OR TERMINATED.

An Application Packet Page 2

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