Child Care Subsidy Application Form (Page 4 of 4) in pdf

Variable Work Schedule/Child Care Requirements: Explain your work schedule providing as much detail as possible (eg. Number of days, hours

per day worked, etc.). State the actual week days and hours per day that you require child

care in one month.

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Special Needs – Child Care Subsidy Referral (MUST BE COMPLETED BY REFERRING PROFESSIONAL)

Date: ______________________ Child’s Name: _________________________________________________________________________________

Facility: ______________________________________________________

Child will require child care _____________ days per week.

Child will require child care ___________ hours per day.

Reason for referral: (if more space is required please provide an attachment).

__________________________________________________________________________________________________________________________

Length of time required: ___________________________________________________________________________________________________

Referring person’s signature: _________________________________________________________________ Date: _________________________

Profession: _______________________________________________________ Name: _________________________________________________

Address: ____________________________________________________________________________ Phone Number: _______________________

I state that the information given in this Child Care Subsidy Application is true, correct and complete and that I have not withheld any information

which may have an effect on my benefits. I understand I may be liable to criminal prosecution for withholding information or providing false or

misleading information.

Reporting Requirements

I agree to report to the Ministry of Social Services any changes in my circumstances, or the circumstances of my family members, that may affect my

eligibility for benefits, or the eligibility of my family members. I understand some examples of such changes are changes in address, income from any

source, number of dependents, marital status (including common-law relationships), living arrangements and change in reason for child care services. If

I am in doubt as to whether any changes in circumstances will effect my eligibility, I agree to report this to the Ministry of Social Services, Child Care

Subsidy office.

Client Consent

I give my consent to the Ministry of Social Services to obtain and verify information or documents required to confirm my eligibility, or the eligibility

of my family members for benefits under the Child Care Subsidy program. I understand information includes income received from any source,

employment records, marital status (including common-law relationships), and living arrangements of myself or my family members. I give consent to

use my Social Insurance Number and the Health Services Number for myself and all family members for the purposes of administration of the Child

Care Subsidy program.

I give my consent to nay ministry, person, or agency having such information or documents to release them upon written or verbal request to employees

of the Ministry of Social Services. I understand examples include, but are not restricted to, information or documents from: the Ministry of Education,

Advanced Education, Employment and Labour, Human Resources and Skills Development Canada (Employment Insurance), Workers’ Compensation

Board, Saskatchewan Government Insurance, any bank, credit union or other financial institution, any landlord and past employers.

I give consent to the Ministry of Social Services to disclose my information to third parties where the information is necessary to verify and confirm my

eligibility for benefits or to assist in providing additional benefits. I understand third party examples include, but are not restricted to the Ministry of

Education, Advanced Education, Employment and Labour and other social assistance programs.

I give my consent to the Ministry of Social Services to advise my child care facility that my subsidy benefits have been placed on hold. I

understand this information may be shared with the facility as my benefits are paid directly to the child care facility on my behalf.

Signature of Applicant

Signature of Spouse/Common-law

Date |____|_____|____|

Year Month Day

Home telephone number

Please be sure address section has been completed

correctly on Page 1

7781 Rev.2 02/10