Form Cc-001 - Application For Child Care Assistance Page 5
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8CC-001 (7-17) – PAGE 4
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 HIGH SCHOOL OR GED PROGRAM ACTIVITY INFORMATION
Complete this section only if you are under 20 years old and need care while you earn your High School diploma or GED.
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 Code)
PHONE NO.
TEEN PARENT HIGH SCHOOL OR GED PROGRAM ACTIVITY INFORMATION
Complete this section only if your spouse or the
other parent of your child is under 20 years old and needs care while they earn their High School diploma or GED.
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 Code)
PHONE NO.
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)
9.
I attended a trade/vocational school, college or university and
1.
I registered or job searched via DES One Stop Career
made satisfactory progress in the activity.
Centers, DES Job Service, other public or private
10.
I attended work related school or training, or pursued a degree
employment agencies, or independently.
or certificate that will lead to enhanced career opportunities.
2.
I applied for a better job.
11.
I have NOT requested TANF (Temporary Assistance to Needy
3.
I have been consistently employed.
Families) Cash Assistance for myself.
4.
I was laid-off but found new employment within 60 days.
12.
I made contact with DES Child Support Enforcement about
5.
I left one job for a better job (higher pay, more hours, or
support from an absent parent or paternity establishment.
better benefits).
6.
I consistently demonstrated a net profit in my self-
13.
I continued with my treatment plan under the direction of a
employment activity.
physician, psychiatrist, or psychologist.
14.
I followed a domestic violence/homeless shelter case plan.
7.
I attended remedial education for the attainment of a high
15.
I completed or am in the process of completing a drug/alcohol
school diploma or GED.
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?
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?
YOUR HOUSING STATUS
The questions below apply to the children whom you are applying to receive Child Care Assistance for.
Yes
No Does your child lack a fixed, regular, and adequate night time residence? Any of the situations listed below could apply:
Sharing the housing of other persons due to loss of housing, economic hardship, or similar reason,
•
•
Living in motels, hotels, trailer parks, or camping grounds due to no choice of your own
•
Living in emergency or transitional shelters; or
•
A primary nighttime residence is not designed for ordinarily use as a regular sleeping accommodation such as
cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings.
Yes
No
Do you and your child reside in a homeless or domestic violence shelter?
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