An Application Packet (Page 3 of 14) in pdf

Child Care Assistance

Eligibility Form

Note: Form must be complete; failure to do so will delay your determination for eligibility, and assistance may be discontinued or denied.

Parent or Caretaker Info:

Sex: ❍ Female

❍ Male

Last Name

First Name

*SSN

❍ Single

❍ Married

❍ Separated

❍ Divorced

❍ Widowed

Date of Birth:

Marital Status:

Ethnicity: Hispanic or Latino? ❍ Yes

❍ No

Race: ❍ Caucasian

❍ African-American

❍ American Indian or Alaskan Native

❍ Yes

❍ No

❍ Native Hawaiian or Other Pacific Islander

❍ Asian

❍ Unknown

Are you currently or have been in Foster Care?

Are you a veteran or spouse of veteran? ❍ Yes

❍ No

❍ Yes

❍ No

If yes, are you currently in High School or GED? ❍ Yes

❍ No

Are you a Teen Parent?

Current military deployment ? ❍ Yes

❍ No

Physical Address

Apt#

County

City/State/Zip

Mailing Address (if different than above)

Apt#

City/State/Zip

Home Phone

Cell Phone

Email Address

Employer:

School:

Address:

City/State/Zip:

Work Phone:

Ext:

Hours:

Date of Enrollment:

Hours Working per Week:

Hourly Pay Rate (required): $

Training/Certification Degree you are pursuing:

Date of Hire:

❍ Weekly

❍ Monthly

❍ Bi-weekly

❍ Bi-monthly

Pay Frequency:

Other Monthly Income:

Tips $

Unemployment $

Lottery (+ $600) $

Pensions $

Retirement $

Workman’s Comp $

Alimony $

Bonuses

Self Employment $

Rent income $

Court Settlements $

Estate/Trust $

Commission $

401K pay out $

Interest/Div $

Disability $

Other $

Do you or your spouse (other parent in household) receive any of the following?

❍ Yes

❍ No

Housing Assistance: ❍ Yes ❍ No

Social Security

❍ Yes ❍ No (If yes, provide documentation of amount)

Food Stamps:

Child Support

❍ Yes

❍ No

❍ Court ordered, but I do not receive it

Amount $

If receiving child support, please circle source:

OAG Office

Court Ordered

Informal Arrangement

(please see attached instructions)

TANF

❍ Yes

❍ No

SSI

❍ Yes

❍ No

TANF for whom?

(If yes, supply documentation of amount)

SSI for whom?

Spouse or Other Parent in Household:

Sex: ❍ Female

❍ Male

Last Name

First Name

*SSN

❍ Single

❍ Married

❍ Separated

❍ Divorced

❍ Widowed

Date of Birth:

Marital Status:

Ethnicity: Hispanic or Latino? ❍ Yes

❍ No

❍ Caucasian

❍ African-American

❍ American Indian or Alaskan Native

Race:

Are you a veteran? ❍ Yes

❍ No

❍ Native Hawaiian or Other Pacific Islander

❍ Asian

❍ Unknown

Employer:

School:

Address:

City/State/Zip:

Work Phone:

Ext:

Hours:

Date of Enrollment:

Hours Working per Week:

Hourly Pay Rate (required): $

Training/Certification Degree you are pursuing:

Date of Hire:

❍ Weekly

❍ Monthly

❍ Bi-weekly

❍ Bi-monthly

Pay Frequency:

Other Monthly Income:

Tips $

Unemployment $

Lottery (+ $600) $

Pensions $

Retirement $

Workman’s Comp $

Alimony $

Bonuses

Self Employment - $

Rent income $

Court Settlements $

Estate/Trust $

Commission $

401K pay out $

Interest/Div $

Disability $

Other $

Page 1

Updated 1-13

Form 2050A

An Application Packet Page 3

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