California State Preschool & Center Based Child Care - Preliminary Application Page 4

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PLEASE NOTE:
Preliminary applications for subsidized child care services will not be accepted without documentation of
monthly family income.
Office Use Only
I hereby certify that I have all source of income reported
Date/Time Preliminary Application was Received:__________
Ranking Number: ____________
Staff Initials: ______
OI
15%
Pb:dt:prelimapp

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