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CCA-1194A FORNA (7-15)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Child Care Administration

INFORMATION NEEDED TO DETERMINE ELIGIBILITY FOR CHILD CARE ASSISTANCE

The DES Child Care Administration offers Child Care Assistance programs for low-income families who are working, teen parents

in high school or GED classes, homeless/domestic violence shelter residents and families who are unavailable or unable to care for

their children due to a physical or emotional condition. You MUST provide a completed Application for Child Care Assistance

(CC-001) in order to make sure your Child Care Specialist is able to determine eligibility.

The check list below is a list of items that may be needed with your Child Care Application. Please provide any of the

documents below that match your families’ current situation. You may contact your Local Child Care Office with any questions

you may have.

Proof of U.S. citizenship or legal residency and Identity for the person applying

Earned Income for the past month/30-days (pay stubs, statement from your employer if newly employed listing your hourly

rate, number of hours worked per week, how often paid and the date of the 1

full check).

Self-Employment Income and business related receipts (monthly self-employment records or current year self-employment

tax return)

Unearned Income (i.e. direct payments of child support, social security income, veteran’s benefits, guardianship, foster, or

adoption subsidy, loans or cash gifts)

Verification of school attendance for teen parents (under the age of 20)

Verification of Shelter Residency (You must provide a current statement from the shelter specifying the number of hours per

day, days per week, and duration of your current shelter required activity)

Verification of Relationship (birth certificates) or Legal Guardianship Documents (when you are not the natural, step or

adoptive parent of the child(ren) who need care)

Medical Statement (please speak to your Specialist to get the form needed to fulfill this requirement).

Child Care Provider Selection (if you need assistance with selecting a provider, contact Child Care Resource & Referral

1-800-308-9000 or visit )

Notes: _____________________________________________________________________________________________________

___________________________________________________________________________________________________________

I understand that if I knowingly submit false information or conceal a material fact on the application I may be charged with FRAUD

pursuant to A.R.S. 13-2311, a class 5 felony. I understand that I will be responsible for all overpayments.

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. The

Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity.

For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair

accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you

to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will

not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in

advance if at all possible. 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.

Form Cca-1194a Forna - Information Needed To Determine Eligibility For Child Care Assistance