Subsidized Child Care Application Form - Commonwealth Of Pennsylvania Page 6

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Affidavit

I affirm that I have read or have had this application read to me in full and that I have received a written copy of the Rights and Responsibilities form on page 11. All informa-

tion I have given is true, correct and complete to the best of my ability, knowledge and belief. I understand that information contained in this application may be shared with other

Department of Human Services programs and the Office of the Inspector General. Further, I understand that I can be penalized by fine or imprisonment or subsidized child care

ineligibility for making any false statements or for my failure to report a change that I am required to report. I understand the changes I am required to report are listed on the

Rights and Responsibilities form on page 11. I understand that if I receive child care for which I was not eligible, I will be required to pay back the cost of the child care I received

during the period of time when I was ineligible.

Parent/Caretaker Signature(s)

Date

Parent/Caretaker Signature required during the face-to-face interview

Date

DO NOT WRITE IN THIS SPACE (for CCIS use only)

PELICAN Record #:

DATE/TIME STAMP

Application received by CCIS on:

All required verification received by CCIS on:

Does this case involve special circumstances?

Yes