Form Lchs 4234 - Ccap Waitlist Pre-Eligibility Questionnaire Page 2
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1
2Child(ren) Information
Child One:
Child Two:
Name: _________________________________
Name: _________________________________
Social Security #: ________________________
Social Security #: ________________________
Date of Birth: _____________________
Date of Birth: _____________________
Gender:
Male
Female
Gender:
Male
Female
Is this Child in school?
Yes
No
Is this Child in school?
Yes
No
Does this child have special needs?
Yes
No
Does this child have special needs?
Yes
No
Child Three:
Child Four:
Name: _________________________________
Name: _________________________________
Social Security #: ________________________
Social Security #: ________________________
Date of Birth: _____________________
Date of Birth: _____________________
Gender:
Male
Female
Gender:
Male
Female
Is this Child in school?
Yes
No
Is this Child in school?
Yes
No
Does this child have special needs?
Yes
No
Does this child have special needs?
Yes
No
Child Five:
Child Six:
Name: _________________________________
Name: _________________________________
Social Security #: ________________________
Social Security #: ________________________
Date of Birth: _____________________
Date of Birth: _____________________
Gender:
Male
Female
Gender:
Male
Female
Is this Child in school?
Yes
No
Is this Child in school?
Yes
No
Does this child have special needs?
Yes
No
Does this child have special needs?
Yes
No
Is there any unearned income in the household?
Yes
No
If YES, please write in the amount of MONTHLY income for each category:
Child Support
$
Retirement Benefits
$
Worker's Compensation
$
Alimony/Maintenance
$
Veteran's Benefits
$
Interest on savings, CD
$
Unemployment
$
Military Allotment
$
Dividends on stocks/bonds
$
SSDI
$
Cash contributions
$
Annuities
$
SSI
$
TANF/Colorado Works
$
Other
$
Is anyone in your household paying court-ordered child support for children not in the home?
Yes
No
If yes, how much is being paid per month? $_____________
FOR COUNTY USE
ONLY
HH Size
<130% FPL
HH Size
<130% FPL
Date:________________
Tech:______________
2
$1,680
6
$3,422
HH Size:______________
Income:____________
3
$2,116
7
$3,858
CSE Sanction?
Yes No
Unpaid PFs? Yes
No
4
$2,551
8
$4,293
Waitlist Eligible? Yes No
Priority?
Yes
No
5
$2,987
9
$4,729
HH #:
Case #:
DEPARTMENT OF HUMAN SERVICES
Child Care Assistance Program
1501 Blue Spruce Drive
Fort Collins, CO 80524
LCHS 4234 (1/14)
Page 2 of 2
(970) 498-6300
Fax (970) 498-7987
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