Form Cc-001 - Application For Child Care Assistance Page 4
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8CC-001 (7-17) – PAGE 3
UNEARNED INCOME (You must answer either Yes or No. You must provide information if Yes.)
AMOUNT
HOW OFTEN
NAME OF PERSON
SOURCE
YES or NO
RECEIVED
RECEIVED
RECEIVING INCOME
$
No Cash Assistance
Yes
$
No Social Security/SSI, SSA
Yes
$
Yes
No Child Support ATLAS # / Court Order #
No Identify other income sources (circle all that apply):
$
Yes
Gifts, Loans, Unemployment Insurance, Rental Income,
Interest, VA, Income from Absent Parent(s), Friends or
Relatives, Other describe):__________________________
CHILD SUPPORT PAID OUT
Yes
No
Do you or your spouse pay child support? If yes, complete below:
WHO IS PAYING THE SUPPORT
FOR WHOM PAID (Name of child)
MONTHLY AMOUNT PAID
$
YOUR EMPLOYMENT ACTIVITY INFORMATION
List all jobs. If you have more than two jobs provide additional information on a separate sheet.
EMPLOYER’S NAME
WORK PHONE NO.
START DATE
EMPLOYER’S ADDRESS (No., Street, City, State, ZIP Code)
ARE YOU ON LEAVE FROM THIS JOB? If so, enter your leave start and end dates.
AVG. HOURS WORKED PER WEEK (or range of hours if schedule varies)
LEAVE START DATE: _____________
LEAVE END DATE: ______________
HOURLY WAGE OR MONTHLY SALARY
HOW OFTEN PAID (Check one)
$
Weekly
Every two weeks
Monthly
Twice a month – Pay Dates:______________
ADDITIONAL INCOME (
all that apply)
TOTAL AMOUNT OF ADDITIONAL INCOME
HOW OFTEN ADDITIONAL INCOME RECEIVED (
one)
$
Bonuses
Tips
Commissions
Daily
Weekly
Monthly
Yearly
Overtime pay
Every two weeks
Twice a month – Pay Dates:____________
SECOND EMPLOYER’S NAME (If you have a second job)
WORK PHONE NUMBER
DATE PRESENT JOB BEGAN
SECOND EMPLOYER’S ADDRESS (No., Street, City, State, ZIP Code)
ARE YOU ON LEAVE FROM THIS JOB? If so, enter your leave start and end dates.
AVG. HOURS WORKED PER WEEK (or range of hours if schedule varies)
LEAVE START DATE: _____________
LEAVE END DATE: ______________
HOURLY WAGE OR MONTHLY SALARY
HOW OFTEN PAID (CHECK ONE)
Weekly
Every two weeks
Monthly
Twice a month – Pay Dates:______________
$
ADDITIONAL INCOME (
all that apply)
TOTAL AMOUNT OF ADDITIONAL INCOME
HOW OFTEN ADDITIONAL INCOME RECEIVED ( one)
$
Bonuses
Tips
Commissions
Daily
Weekly
Monthly
Yearly
Every two weeks
Twice a month – Pay Dates:____________
Overtime pay
EMPLOYMENT ACTIVITY INFORMATION OF SPOUSE OR OTHER PARENT OF CHILD(REN) WHO LIVES WITH YOU
Does this person have more than two jobs?
Yes
No
If “yes,” provide additional information on a separate sheet.
EMPLOYER’S NAME
WORK PHONE NO.
START DATE
EMPLOYER’S ADDRESS (No., Street, City, State, ZIP Code)
ARE YOU ON LEAVE FROM THIS JOB? If so, enter your leave start and end dates.
AVG. HOURS WORKED PER WEEK (or range of hours if schedule varies)
LEAVE START DATE: _____________
LEAVE END DATE: ______________
HOURLY WAGE OR MONTHLY SALARY
HOW OFTEN PAID (CHECK ONE)
$
Weekly
Every two week
Monthly
Twice a month – Pay Dates:__________
ADDITIONAL INCOME ( all that apply)
TOTAL AMOUNT OF ADDITIONAL INCOME
HOW OFTEN ADDITIONAL INCOME RECEIVED ( one)
$
Bonuses
Tips
Commissions
Daily
Weekly
Monthly
Yearly
Every two weeks
Twice a month – Pay Dates:____________
Overtime pay
SECOND EMPLOYER’S NAME (If you have a second job)
WORK PHONE NO.
DATE PRESENT JOB BEGAN
SECOND EMPLOYER’S ADDRESS (No., Street, City, State, ZIP Code)
ARE YOU ON LEAVE FROM THIS JOB? If so, enter your leave start and end dates.
AVG. HOURS WORKED PER WEEK (or range of hours if schedule varies)
LEAVE START DATE: _____________
LEAVE END DATE: ______________
HOURLY WAGE OR MONTHLY SALARY
HOW OFTEN PAID (CHECK ONE)
$
Weekly
Every two weeks
Monthly
Twice a month – Pay Dates:__________
ADDITIONAL INCOME ( all that apply)
TOTAL AMOUNT OF ADDITIONAL INCOME
HOW OFTEN ADDITIONAL INCOME RECEIVED ( one)
$
Bonuses
Tips
Commissions
Daily
Weekly
Monthly
Yearly
Every two weeks
Twice a month – Pay Dates:____________
Overtime pay
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