An Application Packet (Page 4 of 14) in pdf

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

Information Regarding Each Child Needing Care (children over 13 years of age are typically not eligible for assistance):

Sex: ❍ Female

❍ Male

1. Last Name

First Name

*SSN

❍ Son/daughter

❍ Niece/nephew

❍ Other

Date of Birth:

Relationship to Parent/Caretaker:

❍ Yes

❍ No

(If relationship is not son or daughter, do you have legal custody or proof of custody for this child?)

Does child have a disability? ❍ Yes ❍ No

Race: ❍ Caucasian ❍ African-American ❍ American Indian/Alaskan Native

Ethnicity: Hispanic/Latino?

❍ Native Hawaiian/Other Pacific Islander

❍ Asian

❍ Unknown

❍ Yes ❍ No

❍ Full Day

❍ Before/After School

If yes, please list disability:

Current Grade Level:

Type of Care Needed:

Sex: ❍ Female

❍ Male

2. Last Name

First Name

*SSN

❍ Son/daughter

❍ Niece/nephew

❍ Other

Date of Birth:

Relationship to Parent/Caretaker:

❍ Yes

❍ No

(If relationship is not son or daughter, do you have legal custody or proof of custody for this child?)

Does child have a disability? ❍ Yes ❍ No

Race: ❍ Caucasian ❍ African-American ❍ American Indian/Alaskan Native

Ethnicity: Hispanic/Latino?

❍ Native Hawaiian/Other Pacific Islander

❍ Asian

❍ Unknown

❍ Yes ❍ No

❍ Full Day

❍ Before/After School

If yes, please list disability:

Current Grade Level:

Type of Care Needed:

Sex: ❍ Female

❍ Male

3. Last Name

First Name

*SSN

❍ Son/daughter

❍ Niece/nephew

❍ Other

Date of Birth:

Relationship to Parent/Caretaker:

❍ Yes

❍ No

(If relationship is not son or daughter, do you have legal custody or proof of custody for this child?)

Does child have a disability? ❍ Yes ❍ No

Race: ❍ Caucasian ❍ African-American ❍ American Indian/Alaskan Native

Ethnicity: Hispanic/Latino?

❍ Native Hawaiian/Other Pacific Islander

❍ Asian

❍ Unknown

❍ Yes ❍ No

❍ Full Day

❍ Before/After School

If yes, please list disability:

Current Grade Level:

Type of Care Needed:

Sex: ❍ Female

❍ Male

4. Last Name

First Name

*SSN

❍ Son/daughter

❍ Niece/nephew

❍ Other

Relationship to Parent/Caretaker:

Date of Birth:

❍ Yes

❍ No

(If relationship is not son or daughter, do you have legal custody or proof of custody for this child?)

Does child have a disability? ❍ Yes ❍ No

Race: ❍ Caucasian ❍ African-American ❍ American Indian/Alaskan Native

Ethnicity: Hispanic/Latino?

❍ Native Hawaiian/Other Pacific Islander

❍ Asian

❍ Unknown

❍ Yes ❍ No

❍ Full Day

❍ Before/After School

If yes, please list disability:

Current Grade Level:

Type of Care Needed:

Information on Other Members of Household:

Sex: ❍ Female

❍ Male

1. Last Name

First Name

*SSN

Relationship to Parent/Caretaker:

Ethnicity: Hispanic or Latino? ❍ Yes

❍ No

Date of Birth:

❍ Caucasian

❍ African-American

❍ American Indian or Alaskan Native

❍ Native Hawaiian or Other Pacific Islander

❍ Asian

❍ Unknown

Race:

Sex: ❍ Female

❍ Male

2. Last Name

First Name

*SSN

Relationship to Parent/Caretaker:

Ethnicity: Hispanic or Latino? ❍ Yes

❍ No

Date of Birth:

❍ Caucasian

❍ African-American

❍ American Indian or Alaskan Native

❍ Native Hawaiian or Other Pacific Islander

❍ Asian

❍ Unknown

Race:

Total Number of Persons in Household:

What is the total number of persons living in the household (this includes parent/caretaker, spouse, all children, and any

other dependent persons)?

I understand that: (1) a person who obtains or attempts to obtain, by fraudulent means, services to which the person is not entitled may be prosecuted under applicable state and federal

laws; (2) I am entitled to be notified about my eligibility for services within 20 calendar days from the date of this application; (3) I, or my representative, may appeal denial, reduction, or

termination of services; (4) services will be provided without regard to sex, race, creed, color, national origin, or disability; (5) the information on this application is confidential; (6) By

signing this form, I am applying for services from Workforce Solutions Northeast Texas. The income I have reported is correct and includes all the required income sources listed on

this form. I understand that failure to report all family income may cause my child care to be terminated and I may have to repay the amount owed. I give permission to Workforce

Solutions Northeast Texas to contact a third party to verify income or family size, and use the Social Security numbers listed for identification and verification of Social Security benefits

and income. *SSN information is voluntary.

All information provided represents a complete and accurate statement of my family’s circumstances at the time of application. I agree to report any changes to this

information within 10 calendar days of the change.

Parent or Caretaker Signature:

Date:

Eligibility Certification Form Page 2

Updated 1-13

Form 2050A