Form Cc-001 - Application For Child Care Assistance - Arizona Department Of Economic Security Page 5
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8CC-001 (10-16) – PAGE 5
YOUR SELF-EMPLOYMENT ACTIVITY INFORMATION
Yes
No
Are you currently self-employed? If Yes, describe your business:
Business Type:
Corporation
Owned by yourself
A Partnership (Name all partners):
Yes
No Can you set your own schedule?
Yes
No
Do you have business expenses from Self-Employment?
Who pays you?
Individual Customer
Parent Company
Other (explain):
If newly self-employed, how much gross income (before deducting any business expenses) do you think you will earn each month?
$
SPOUSE OR OTHER PARENT SELF-EMPLOYMENT ACTIVITY INFORMATION
Yes
No Is this person currently self-employed? If Yes, describe their business:
Business Type:
Corporation
Owned by their self
A Partnership (Name all partners):
Yes
No Can they set their own schedule?
Yes
No
Do they have business expenses from Self-Employment?
Who pays them?
Individual Customer
Parent Company
Other (explain):
If newly self-employed, how much gross income (before deducting any business expenses) do you think they will earn each month?
$
TEEN PARENT INFORMATION
HIGH SCHOOL / GED PROGRAM NAME
TERM/SEMESTER BEGIN DATE
TERM/SEMESTER END DATE
ATTACH YOUR CLASS SCHEDULE
TO APPLICATION
SCHOOL’S ADDRESS OR WEBSITE ADDRESS (No. Street, City, State, ZIP)
PHONE NUMBER
(
)
SPOUSE OR OTHER PARENTS HIGH SCHOOL OR GED PROGRAM ACTIVITY INFORMATION
Is this person attending high school, or a GED program?
Yes
No
HIGH SCHOOL’S NAME / GED PROGRAM NAME
TERM/SEMESTER BEGIN DATE TERM/SEMESTER END DATE
ATTACH THEIR CLASS
SCHEDULE TO APPLICATION
SCHOOL’S ADDRESS OR WEBSITE ADDRESS (No. Street, City, State, ZIP)
PHONE NUMBER
(
)
SELF-SUFFICIENCY STATEMENT (must check at least one box)
�
I have made the following efforts to improve my skills and move toward self-sufficiency in the last 12 months. (
all that apply)
1.
I registered or job searched via DES One Stop Career
9.
I attended a trade/vocational school, college or university and
made satisfactory progress in the activity.
Centers, DES Job Service, other public or private
employment agencies, or independently.
10.
I attended work related school or training, or pursued a degree
2.
I applied for a better job.
or certificate that will lead to enhanced career opportunities.
3.
I have been consistently employed.
11.
I have NOT requested TANF (Temporary Assistance to Needy
Families) Cash Assistance for myself.
4.
I was laid-off but found new employment within 60 days.
5.
I left one job for a better job (higher pay, more hours, or
12.
I made contact with DES Child Support Enforcement about
better benefits).
support from an absent parent or paternity establishment.
6.
I consistently demonstrated a net profit in my self-
13.
I continued with my treatment plan under the direction of a
physician, psychiatrist, or psychologist.
employment activity.
7.
I attended remedial education for the attainment of a high
14.
I followed a domestic violence/homeless shelter case plan.
school diploma or GED.
15.
I completed or am in the process of completing a drug/alcohol
rehabilitation or court ordered community service program.
8.
I attended English for Speakers of Other Languages (ESOL)
16.
Other ___________________________________________
classes.
YOUR MILITARY STATUS (You must answer either yes or no)
Yes
No
Are you currently active duty (serving full-time) in the US Military?
Yes
No
Are you currently a member of a National Guard Unit?
Yes
No
Are you currently a member of a military reserve unit?
YOUR SPOUSE/OTHER PARENT MILITARY STATUS (Answer yes or no if your spouse or the other parent is residing with you)
Yes
No
Is the spouse/other parent currently active duty (serving full-time) in the US Military?
Yes
No
Is the spouse/other parent currently a member of a National Guard Unit?
Yes
No
Is the spouse/other parent currently a member of a military reserve unit?
YOUR RESIDENCE STATUS according to McKinney-Vento Homeless Assistance Act (Please answer all that apply)
The questions below apply to the children whom you are applying to receive Child Care Assistance for.
Yes
No
Are they sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason?
Yes
No
Are they living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate
accommodations?
Yes
No
Are they living in emergency or transitional shelters?
Yes
No
Are they abandoned in hospitals?
Yes
No
Are they awaiting foster care placement?
Yes
No
Do they have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a
regular sleeping accommodation for human beings?
Yes
No
Are they living in cars?
Yes
No
Are they living in parks or other public spaces?
Yes
No
Are they living in abandoned buildings?
Yes
No
Are they living in substandard housing?
Yes
No
Are they living in bus or train stations or similar settings?
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