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CC-001 (10-16) – PAGE 1

DATE RECEIVED

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Child Care Administration

APPLICATION FOR CHILD CARE ASSISTANCE

INFORMATION NEEDED TO DETERMINE ELIGIBILITY FOR CHILD CARE ASSISTANCE

The DES Child Care Administration offers Child Care Assistance programs for low-income families who are working, teen

parents in high school or GED classes, homeless/domestic violence shelter residents and families who are unavailable or

unable to care for their children due to a physical or emotional condition. You MUST provide a completed Application for

Child Care Assistance (CC-001) in order to make sure your Child Care Specialist is able to determine eligibility.

The check list below is a list of items that may be needed with your Child Care Application. Please provide any of the

documents below that match your families’ current situation. You may contact your Local Child Care Office with any

questions you may have.

Proof of U.S. citizenship or legal residency for the applicant.

Copy of your most recent paycheck stub, or current statement signed by your employer verifying the gross wages

of your most recent paycheck, frequency of pay and days/hours of employment. Also include verification of tips,

bonuses, commissions or allowances and the frequency of payment (weekly, bi-weekly, twice a month, or monthly).

Self-Employment Income and business related receipts (monthly self-employment records or US Individual

Income Tax Return with attached schedules, from last year’s tax return).

Unearned Income (i.e. direct payments of child support, social security income, veteran’s benefits, guardianship,

foster, or adoption subsidy, loans or cash gifts).

Verification of school attendance for teen parents (under the age of 20).

Verification of Shelter Residency (You must provide a current statement from the shelter specifying the number

of hours per day, days per week, and duration of your current shelter required activity).

Verification of Relationship (birth certificates) or Legal Guardianship Documents (when you are not the natural,

step or adoptive parent of the child(ren) who need care).

Medical Statement (please speak to your Specialist to get the form needed to fulfill this requirement).

Child Care Provider Selection (if you need assistance with selecting a provider, contact Child Care Resource &

Referral 1-800-308-9000 or visit ).

Notes:

_________________________________________________________________________________________________

If you, your representative, or any household member hides or provides false information purposely to receive or continue

to receive child care assistance that you are not entitled to, that person will be subject to:

•

Criminal Prosecution

•

Fines

•

Imprisonment

•

Other penalties provided for by state and federal laws

If you knowingly break these rules and receive child care assistance you are not entitled to we will disqualify you from

receiving services for:

•

6 months for the first violation

•

12 months for the second violation

•

Permanently for the third violation

I understand that if I knowingly submit false information or conceal a material fact on the application I may be charged with

FRAUD pursuant to A.R.S. 13-2311, a class 5 felony. I understand that I will be responsible for all overpayments.

If you need assistance in locating a DES Child Care office in your area:

Please visit https://des.az.gov; or contact the DES Child Care Administration at 602-542-4248.

Form Cc-001 - Application For Child Care Assistance - Arizona Department Of Economic Security

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