Application For Child Care Assistance
ADVERTISEMENT
1
2
3
4CCAP 2
Louisiana Department of Social Services
OFFICE USE ONLY
Rev. 03/07
Office of Family Support
SSN
02/06 Issue Obsolete
Child Care Assistance Program
Worker
New Application
Application for Child Care Assistance
Redetermination
Redet M/Y
1. IDENTIFYING INFORMATION: This form should be completed by the parent or other household member who is responsible for paying
child care costs.
PLEASE PRINT ALL INFORMATION
NAME: LAST
FIRST
MIDDLE INITIAL
HOME
ADDRESS:
STREET
APT. NO.
CITY
PARISH
ZIP
MAILING
STREET/
ADDRESS:
P.O. BOX
APT. NO.
CITY
PARISH
ZIP
TELEPHONE #S:
HOME: (
)
WORK: (
)
OTHER PHONE: (
)
2.
HOUSEHOLD COMPOSITION: For this program, a household includes these individuals who live together: Head of Household,
Head of household’s legal or non-legal spouse, and all dependent children under age 18. List yourself first, then other household
members with the oldest members listed first.
M
ARITAL
R
T
N
(F
, M
, L
)
ELATIONSHIP
O
B
R
S
(O
) SSN
AME
IRST
I
AST
IRTH DATE
ACE
EX
PTIONAL
S
TATUS
Y
OURSELF
Self
Is anyone listed above pregnant?
Yes
No If yes, list the person's name and due date.
Name:
Due Date:
Is any adult or parent listed above disabled?
Yes
No If yes, list the person's name and attach verification of disability (doctor's
statement, etc) Name:
Are all children listed above U. S. citizens?
Yes
No If no, list their names:
3.
CHILDREN NEEDING CARE: List the times each day that child care is needed for each child (if school-aged children need care
both before and after school, list both times; example: 7:00 to 8:00 and 3:30 to 6:00). NOTE: If you have not yet selected a child
care provider, enter the child’s name, age, time each day care is needed, and check the type of care that you plan to use.
P
/
T
ROVIDER
IME
T
C
C
YPE OF
ARE
OST OF
N
O
C
A
N
/A
/P
# O
P
C
N
AME
F
HILD
GE
AME
DDRESS
HONE
F
ROVIDER
HILD
EEDED
O
P
C
C
NE
ER
HILD
ARE
R
E
D
ELATIONSHIP
ACH
AY
Child’s Home
Provider’s Home
Class A Center
Other
Child’s Home
Provider’s Home
Class A Center
Other
Child’s Home
Provider’s Home
Class A Center
Other
Child’s Home
Provider’s Home
Class A Center
Other
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal