Application For Child Care Assistance Page 2
ADVERTISEMENT
1
2
3
44.
List children from Item 3 who attend/will attend Head Start, Pre-Kindergarten, Kindergarten, or school this year:
5.
Are immunizations current on all children in need of child care?
Yes
No If no, list their names:
6.
PERSONS WHO ARE EMPLOYED: Enter the name of each parent and person age 18 and over listed in # 2 (on the reverse side)
who is working. List ALL jobs (working means full-time, part-time, temporary, self-employment, or odd-job employment, even if the
job has just started or will end soon). Send in check stubs for the 4 most recent pay periods (for each person who is
employed). If check stubs are not available, we will supply a form for the employer to complete to verify earnings for the 4 most
recent pay periods.
G
H
ROSS
OW
N
A
A
E
W
W
AME
ND
DDRESS
MPLOYMENT
ORK
ORK
P
E
A
O
ERSON
MPLOYED
MOUNT
FTEN
O
E
B
D
H
/W
D
/W
F
MPLOYER
EGIN
ATE
OURS
EEK
AYS
EEK
E
P
ARNINGS
AID
7.
OTHER TYPES OF INCOME: Check the appropriate column next to the type of income that you or any member of your household
receives or has applied for. Send in proof of any income that is checked.
A
MOUNT
S
O
I
RECEIVES
A
F
P
W
A
/R
H
O
OURCE
F
NCOME
PPLIED
OR
ERSON
HO
PPLIED
ECEIVES
OW
FTEN
R
ECEIVED
A. Child Support
B. Alimony
C. Unemployment Benefits
D. SSI-Supplemental Security Income
E. Social Security Benefits
F. Veteran’s Benefits
G. Retirement Benefits
H. Other Disability Benefits
I.
Adoption Subsidy
J. Other Income Type (contributions,
etc.)
PERSONS WHO ARE IN SCHOOL OR TRAINING: Enter the name of each parent and person age 18 and over listed in #2 (on the
8.
reverse side) who is attending a job training or educational program. Send in verification of school or job training attendance,
including the number of hours in class each week and the anticipated date of completion.
A
NTICIPATED
P
I
T
N
A
A
O
S
C
H
/W
C
D
/W
ERSON
N
RAINING
AME
ND
DDRESS
F
CHOOL
LASS
OURS
EEK
LASS
AYS
EEK
C
D
OMPLETION
ATE
9.
PERSONS WHO ARE LOOKING FOR EMPLOYMENT: Enter the name of each parent and person age 18 and over listed in #2
who needs child care assistance to look for work:
10.
CASH ASSISTANCE FROM FITAP (Family Independence Temporary Assistance Program): Does any member of your
household receive FITAP, or has anyone’s FITAP case been closed within the past 2 months?
Yes
No If yes, is/was this
person receiving child care assistance?
Yes
No If either question above is answered yes, list the name(s) of the person(s)
receiving assistance:
SPECIAL NEEDS: Does any child, under age 18, need specialized child care because of a physical, mental, or emotional
11.
condition?
Yes
No If yes, who?
For what type of condition?
Is any child receiving SSI or other disability benefits?
Yes
No If yes, send copy of award letter or copy of a recent check.
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal