Subsidized Child Care Application Form - Commonwealth Of Pennsylvania Page 5

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Employment and Self-Employment

Date filed last Business

Is this person

Employer’s

Tax Return (Schedule C) if

Employer’s Name

Employer’s Address

Self-Employed?

Phone #

self-employed

Yourself

(

)

£ Yes £ No

Spouse/Live-in father

(

)

£ Yes £ No

of child needing care

You MUST attach proof of the hours and days you work. Proof includes a copy of your work schedule, a letter from your employer that states the hours and days you

work or an Employment Verification form. Copies of Employment Verification forms are included on pages 7 through 10 for your convenience.

Income and Expenses

DOES ANYONE IN YOUR HOME HAVE ANY INCOME?

Yes

If yes, list income you have already received this month or expect to receive this month.

Types/sources of income include, but are not limited to:

•

Wages

•

SSI

•

Rent

•

Interest

•

Room and board

• Social Security

•

Self-employment

•

Pensions

•

Money for college or training

•

Unemployment or Workers’ Compensation

•

Commissions

• Other

•

Child support

•

Union pay

•

Dividends

•

Money Received for Babysitting Children

•

Spousal support/alimony

Type/Source

Person With Income

How Often Received?

How Much?

Date Received

Of Income

ATTACH PROOF OF ALL INCOME your family received within the past 30 days. Proof includes pay stubs, award letters or statements from your employer that include how often

you are paid and how much you earn per pay. If you are self-employed, attach a copy of your most recent tax return and attachments, including receipts.

Have you had medical expenses that were not covered by your insurance within the past 90 days, which will continue for the next six months?

Yes

If YES, attach proof of your medical expenses. Proof includes copies of doctor bills, hospital bills, dental bills, health care premiums, bills for prosthetic devices, medication

expenses and/or bills for durable medical equipment.

Do you or your current spouse/live-in father of the child needing care pay child support or alimony?

Yes

If yes, complete the section below and attach proof of

payment of the child support or alimony you are ordered to pay.

Name of person for whom you pay child support or alimony (Last name, First name, MI)

Relationship to you?

How much do you pay?

How often do you pay?

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