Form Cc-001 - Application For Child Care Assistance Page 6
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8CC-001 (7-17) – PAGE 5
DO YOU NEED ANY ADDITIONAL INFORMATION? (
all that apply)
Locating a child care provider
Child support assistance
Immunization assistance
Aging services
WIC (Women, infants, children) food and nutrition service
Unemployment assistance
Adoption assistance
Housing assistance
Developmental disabilities assistance
Utility assistance
Hearing and visually impaired assistance
Employment assistance
Medical assistance
Substance abuse assistance
Dental assistance
Mental health assistance
Domestic violence assistance
Tax assistance
Domestic violence/homeless shelter
Legal aid assistance
Financial assistance - TANF (Cash Assistance)
Family counseling
Food and nutrition assistance
Other: _________________________________________
TAX CLAIMANT QUESTIONNAIRE
You must complete this questionnaire to determine if there are any relatives living with you who must be included in your family
size (and have their income counted) based on whether they intend to claim you, or your family members (your spouse, your
children or the other parent of your children who lives with you, or the children of the other parent) as a dependent when filing
their federal or state income tax return.
1. Are you the parent (natural, step or adoptive) of the child(ren) needing child care?
If the answer is YES, continue to Question #2.
Yes
No
If the answer is NO, you are NOT required to complete Question #2.
READ and SIGN the Rights and Responsibilities on page 6, before submitting this application.
2. Do you have an adult relative living with you who intends to claim you, your child(ren), or your spouse [or other parent of your
child(ren), or the child(ren) of your spouse or other parent from a prior relationship as dependents on their State or Federal income
tax return (when they file their taxes in the next calendar year)?
No
By answering NO and signing the Rights and Responsibilities on page 6 of this application you have
declared that either no adult relative is living with you or that an adult relative living with you does NOT
intend to claim you or any of your family members as dependents on their State or Federal income tax return
(when they file their taxes in the next calendar year).**
Yes
If the answer is YES, you and the adult relative MUST complete and sign Section B of the Tax Claimant
Declaration, CCA-1105A (available at any DES Child Care Assistance office).**
Don’t know
If you stated that you don’t know, then you and your adult relative must determine through discussion,
whether they intend to claim you or any of your family members as a dependent on their State or Federal
income tax return. You and your relative must complete and sign the Tax Claimant Declaration, CCA-
1105A and return it to your DES Child Care Specialist.**
**
IMPORTANT: The Department of Economic Security, Child Care Administration cannot advise you or your family whether a relative
may claim a member of your family as a dependent for income tax purposes. If you need help finding out whether a relative who
lives with you may be able to claim you or any of your family members as dependents for income tax purposes, the Department of
Economic Security recommends that you seek help through the U.S. Internal Revenue Service at , and the Arizona
Department of Revenue at , or consult a tax professional.
TAX CLAIMANT’S (RELATIVE’S) INCOME
If you indicated that a relative intends to claim you or your family members as dependents on their income tax return, you must
answer either YES or NO for each type of income source. Check () YES if the Tax Claimant, and/or their spouse have received
or will receive income from any source. Check () NO if no income from that source.
Amount
How Often
Name of Person
YES
NO
Source
Received
Received
Receiving Income
Earned Income/Self-Employment Income
$
Cash Assistance
$
Social Security / SSI, SSA
$
Child Support ATLAS # / Court Order #
$
Any Other Income Source, such as: Gifts, Loans, Unemployment
Insurance, Rental income, Interest, VA or any Income from
$
Absent Parent(s), Friends or Relatives (indicate type):
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