Form Cc-001 - Application For Child Care Assistance Page 3
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8CC-001 (7-17) – PAGE 2
*RACE
LIST THE NAMES OF EVERYONE ELSE
AI: American Indian
WHO LIVES IN YOUR HOME
or Alaskan Native;
DATE
IN THE SPACES BELOW
AS: Asian; BL: Black
OF
(First, M.I, Last)
or African American;
SOC. SEC. NO.
BIRTH
NH: Native Hawaiian
(If you have more than 9 people in your
(MM/DD/YY)
or Other Pacific
home, list their names and relationship to
Islander;
you on a separate sheet of paper.)
WH: White
NAME (First, Middle, Last)
*AI
AS
BL
NH
WH
Y
N
Y
N
Hispanic?
Yes
No
3
If this person is your child, PROVIDE NAME OF CHILD’S OTHER PARENT.
DOES THE OTHER PARENT LIVE WITH YOU?
Yes
No
Yes
No
Does this child have special needs? You must be able to provide verification using one of the documents listed below:
_____________________________
IEP
IFSP
ISP
504 Plan
Diagnosis
Other
:
NAME (First, Middle, Last)
*AI
AS
BL
NH
WH
Y
N
Y
N
Hispanic?
Yes
No
4
If this person is your child, PROVIDE NAME OF CHILD’S OTHER PARENT.
DOES THE OTHER PARENT LIVE WITH YOU?
Yes
No
Yes
No
Does this child have special needs? You must be able to provide verification using one of the documents listed below:
_____________________________
IEP
IFSP
ISP
504 Plan
Diagnosis
Other
:
NAME (First, Middle, Last)
*AI
AS
BL
NH
WH
Y
N
Y
N
Hispanic?
Yes
No
5
If this person is your child, PROVIDE NAME OF CHILD’S OTHER PARENT.
DOES THE OTHER PARENT LIVE WITH YOU?
Yes
No
Yes
No
Does this child have special needs? You must be able to provide verification using one of the documents listed below:
_____________________________
IEP
IFSP
ISP
504 Plan
Diagnosis
Other
:
*AI
AS
BL
NAME (First, Middle, Last)
NH
WH
Y
N
Y
N
Hispanic?
Yes
No
6
If this person is your child, PROVIDE NAME OF CHILD’S OTHER PARENT.
DOES THE OTHER PARENT LIVE WITH YOU?
Yes
No
Yes
No
Does this child have special needs? You must be able to provide verification using one of the documents listed below:
_____________________________
IEP
IFSP
ISP
504 Plan
Diagnosis
Other
:
NAME (First, Middle, Last)
*AI
AS
BL
NH
WH
Y
N
Y
N
Hispanic?
Yes
No
7
If this person is your child, PROVIDE NAME OF CHILD’S OTHER PARENT.
DOES THE OTHER PARENT LIVE WITH YOU?
o
Yes
N
Yes
No
Does this child have special needs? You must be able to provide verification using one of the documents listed below:
_____________________________
IEP
IFSP
ISP
504 Plan
Diagnosis
Other
:
NAME (First, Middle, Last)
*AI
AS
BL
NH
WH
Y
N
Y
N
Hispanic?
Yes
No
8
If this person is your child, PROVIDE NAME OF CHILD’S OTHER PARENT.
DOES THE OTHER PARENT LIVE WITH YOU?
Yes
No
Yes
No
Does this child have special needs? You must be able to provide verification using one of the documents listed below:
_____________________________
IEP
IFSP
ISP
504 Plan
Diagnosis
Other
:
NAME (First, Middle, Last)
*AI
AS
BL
NH
WH
Y
N
Y
N
Hispanic?
Yes
No
9
If this person is your child, PROVIDE NAME OF CHILD’S OTHER PARENT.
DOES THE OTHER PARENT LIVE WITH YOU?
Yes
No
Yes
No
Does this child have special needs? You must be able to provide verification using one of the documents listed below:
_____________________________
IEP
IFSP
ISP
504 Plan
Diagnosis
Other
:
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