Form Cc-001 - Application For Child Care Assistance Page 8
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8DES CHILD CARE SERVICES INFORMATION
CC-001 (7-17) – PAGE 7
REPORT CHANGES IMMEDIATELY
You must report the following changes within 5 work days to your local DES Child Care office: you move, you or any adult in your
household experience a loss of employment, someone moves in or out of your household, your family’s gross monthly income increases
above 85% of the State Median Income (SMI) or you change child care providers. You may be required to submit one or more of the
applicable types of verification listed below.
VERIFICATION REQUIREMENTS
● If you are working, or are in a work study program, provide:
● Copy of your most recent paycheck stub, or
● A current statement signed by your employer verifying the gross wages of your most recent paycheck, frequency of pay and
days/hours of employment. Also include verification of tips, bonuses, commissions or allowances and the frequency of payment.
● If you are self-employed, provide a copy of your annual tax return, or weekly/monthly ledgers verifying gross income, receipts for
business income and expenses for the last six months.
● If you are a teen parent (under the age of 20) attending high school, G.E.D. or E.S.O.L. classes, or remedial education activities in
pursuit of a high school diploma, provide a current statement from the school or training program verifying start and end dates of the
activity, and days/hours of attendance.
VERIFICATION OF OTHER INCOME
● If receiving Unemployment Insurance, Social Security, Veterans' or any other type of benefits, provide a copy of the current award
letter.
● Child Support. If you receive child support payments through a court, provide a current printout verifying the last three months of
payments. If the child support payment is not received through the court, provide the court order or ATLAS number.
● If you pay child support for any children who do not live with you, provide a court order or divorce decree specifying the amount paid
each month and a current paystub showing the child support paid or a printout from the court or child support enforcement agency.
● If you have adult relatives living with you, 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(s) may be
required to complete and sign the Tax Claimant Declaration, CCA-1105A and return it to your DES Child Care Specialist.
● If any of the adult relatives living with you intend to claim you, your child(ren), or your spouse (or other parent of your children), or the
children of your spouse or other parent from a prior relationship as a tax dependent, you are required to provide verification of your
relative’s current income and the current income of your relative’s spouse (if married).
CHILD CARE FOR MEDICAL REASONS
You must provide a current statement from your licensed physician, certified physician assistant, certified nurse practitioner, certified
psychologist, or certified behavioral health specialist explaining how the medical condition prevents you or the other parent in the home
from providing care to your child(ren); the duration and frequency that child care is needed must be specified.
CHILD CARE FOR SHELTER RESIDENT
You must provide a current statement from the shelter specifying the number of hours per day, days per week, and duration of your
current activity.
WAITING LIST REQUIREMENTS
● When a Waiting List is in effect, priority for services will be given to families with income at or below 100% of the Federal Poverty Level
based on the date the application was received by the Department.
● If you are on the Waiting List, you may remain on the list as long as your family continues to meet income and other eligibility
requirements, including continuing to cooperate with the Department to re-determine eligibility as requested. Failure to comply with
the case review process, or to provide requested verification may result in the removal of your name from the Waiting List. Once
removed from the Waiting List, you will need to reapply for child care services. If you re-apply after the review date and you are
determined eligible, your name will be added back to the Waiting List effective the date you reapply.
REQUIREMENTS FOR CASH ASSISTANCE FAMILIES IN EDUCATION/TRAINING ACTIVITIES
If you are receiving Cash Assistance benefits, and are receiving child care services for education/training needs, you must comply with
the Jobs program (if contacted by Jobs) as a requirement for Cash Assistance and child care eligibility. If you are contacted by the Jobs
program, you are required to participate in all Jobs activities as assigned. Failure to comply with Jobs requirements may result in a
sanction; your Cash Assistance benefits may be reduced, and you may lose child care eligibility.
ASSISTANCE IN LOCATING A CHILD CARE PROVIDER
The Child Care Resource and Referral service (CCR&R) can assist you in finding a child care provider that meets your needs. This free
service is available to all families. Please call 1-800-308-9000 for information about locating a child care provider.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in
alternative format or for further information about this policy, contact 602 542-4248; TTY/TDD Services: 7-1-1. Free language assistance
for DES services is available upon request. ● Disponible en espanol en linea o en la oficina local.
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