Form Cc-001 - Application For Child Care Assistance Page 2
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8CC-001 (7-17) – PAGE 1
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Child Care Administration
DATE RECEIVED
APPLICATION FOR CHILD CARE ASSISTANCE
Please complete all sections of this application. Missing or inaccurate information can delay eligibility decisions.
NEW APPLICANT
REDETERMINATION
My child had Child Care through the AZ Department of Child Safety or Tribal Child Protective Services in the last 30 days.
Have you received subsidized child care assistance in another state?
YES
NO
If yes, in what State/County did you receive subsidized child care assistance? ____________________________________________
*
RACE:
AI: American Indian/Alaskan Native; AS: Asian; BL: Black or African American; NH: Native Hawaiian or Other Pacific Islander; WH: White
*
DATE OF BIRTH
YOUR LEGAL NAME
SOC. SEC. NO.
MARITAL STATUS
RACE
(MM/DD/YY)
(First, M.I, Last)
AI
AS
BL
Married
Separated
NH
WH
1
Divorced
Widowed
Hispanic?
Never Been Married
Yes
No
*
LEGAL NAME OF YOUR SPOUSE OR
DATE OF BIRTH
RACE
SOC. SEC. NO.
SPOUSE?
OTHER PARENT LIVING WITH YOU
(MM/DD/YY)
(First, M.I, Last)
AI
AS
BL
NH
WH
2
Yes
No
Hispanic?
Yes
No
OTHER NAMES USED BY YOU (e.g. maiden, alias):
Yes
No
Are you an enrolled member of an American Indian tribe? Which tribe? (Describe):
YOUR ADDRESS INFORMATION
I am enrolled in the Address Confidentiality Program.
APPLICANT’S RESIDENTIAL ADDRESS (House No., Street, Apt. / Space #, City, State ZIP Code)
APPLICANT’S MAILING ADDRESS (If different from residential address)
PHONE NO.
MESSAGE PHONE NO. (alternate phone number)
EMAIL ADDRESS
YOUR CITIZENSHIP/LEGAL RESIDENCY STATUS
Yes
No
Are you a U.S. Citizen?
Yes
No
Are you a Legal Resident in the U.S.?
Document type you will provide for eligibility determination
AZ Driver’s License
U.S. Birth Certificate
Legal Resident Card
:
Other: _________________________________________
YOUR REASONS FOR CHILD CARE SERVICES
Employment
High School GED (under 20 years old)
Medical
Jobs Program
Job Search
(for Grant Diversion participant)
Other (Describe):_________________________________________________________________________________________
YOUR CHILD CARE PROVIDER INFORMATION (If known)
WHICH CHILD CARE PROVIDER HAVE YOU CHOSEN?
PROVIDER’S ADDRESS (No., Street, City, State, ZIP Code)
PHONE NO.
ABSENT HOUSEHOLD MEMBER
Yes
No
Are any household members temporarily out of the home? If yes, Who? ________________________________
REASON FOR ABSENCE
ADDITIONAL INFORMATION
Yes
No
Do your family assets exceed $1,000,000.00 (one million)?
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