An Application Packet (Page 7 of 14) in pdf

Customer Awareness Form

Name of Customer ______________________________________________

Case # _______________

(Please Print Name)

Work/Training/Education:



I understand that I am able to get child care so that I can work, go to school, or be in job training classes. I

cannot get child care if I am not working, going to school, or in job training classes for at least 25 hours a

week for a one parent household or 50 hours a week for a two parent household. If I am no longer working,

no longer in school, or no longer in job training classes for required number of hours, I will notify you within

10 calendar days of the change.

Family/Income:



I understand that my eligibility for child care is based on my family’s income or size. If my family’s income or

size changes, I will notify you within 10 calendar days of the change. [For example, if I get a job or a pay

raise, I must report this to you within 10 calendar days; or, if I get married, a parent of the child(ren) returns

to the home, or other adults reside in the home, I must report this to you within 10 calendar days.]



I understand that it may be considered stealing child care services if I continue to receive child care without

notifying you within 10 calendar days of any changes in my work, training, or education status; my income;

benefits; family; or marital status. I understand that if I fail to notify you within 10 calendar days for any of the

changes in status discussed above, criminal charges may be filed against me with a local prosecuting

authority, my child care may be terminated, and I may have to repay the amount owed.

False Information:



I understand if I provide false information to make myself appear eligible for child care services, criminal

charges may be filed against me with local prosecuting authority, my child care may be terminated, and I

may have to repay the amount owed.

Eligibility Validation:



I understand that information I provide to determine my eligibility is subject to validation through cross-

checks against state and federal databases and that I may be asked to participate in face-to-face interviews

and provide original documents to verify my identity and eligibility for child care services.

I understand that it is my responsibility to report true and correct information to child care services within 10

calendar days. All my questions about reporting eligibility changes were answered before/when I signed this

form.

Customer Signature

Date

An Application Packet Page 7