Subsidized Child Care Application Form - Commonwealth Of Pennsylvania Page 3
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12Frequently Asked Questions
Q. What must I do to get help paying for my child care?
A.
Some of the eligibility rules to receive subsidized child care are: (1) Your family has children under 13 years old. Exceptions are possible for children with
disabilities; (2) Your family meets income guidelines for subsidy. For specific guidelines, call the CCIS; (3) You and your spouse/live-in father of the child
needing care are working at least 20 hours a week OR are working at least 10 hours a week and you are also participating in approved training at least 10 hours
a week; and (4) Your family must pay a portion of your child care costs (co-payment).
Q. How do I know if my family is eligible for the Subsidized Child Care Program?
A.
Complete an application, then take, fax or mail the application to your local CCIS agency. You also will need to have a face-to-face interview with the CCIS
agency. About a month after CCIS receives a signed, dated application, you will get a letter that states if you are eligible to receive help.
Q. Who decides what child care provider or facility I can use?
A.
You do. You choose who cares for your child. It can be a child care center, a small family-run business or even a relative or neighbor that meets the
Department of Human Services’ participation requirements. You should choose child care that meets your child’s needs. The CCIS agency can help you find a
provider.
Tell us about yourself
Address:
Street
City
State
Zip Code
Email address
Home Phone #: (
)
Cell Phone # (if applicable): (
)
Work Phone #: (
)
Where should we call you if we have any questions? Please circle one. HOME / WORK / CELL PHONE Best time to call:
AM / PM
Name & phone # of child care pro-
Child’s school district
Is the child living in
Race (check all that apply)
Ethnicity
& grade?*
the U.S. legally?
(check only one)
vider for the child?
Yes
No
£ African American
£ Native Alaskan/American Indian
£ Asian
£ Hispanic
£ Native Hawaiian/Pacific Islander
£ Caucasian
£ Non-Hispanic
£ African American
£ Native Alaskan/American Indian
£ Asian
£ Hispanic
£ Native Hawaiian/Pacific Islander
£ Caucasian
£ Non-Hispanic
£ African American
£ Native Alaskan/American Indian
£ Asian
£ Hispanic
£ Native Hawaiian/Pacific Islander
£ Caucasian
£ Non-Hispanic
£ African American
£ Native Alaskan/American Indian
£ Asian
£ Hispanic
£ Native Hawaiian/Pacific Islander
£ Caucasian
£ Non-Hispanic
£ African American
£ Native Alaskan/American Indian
£ Asian
£ Hispanic
£ Native Hawaiian/Pacific Islander
£ Caucasian
£ Non-Hispanic
£ African American
£ Native Alaskan/American Indian
£ Asian
£ Hispanic
£ Native Hawaiian/Pacific Islander
£ Caucasian
£ Non-Hispanic
* NOTE: If you are a teen parent, you must provide your school district and grade.
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CY 868 12/15
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