Form Doh-3688 - Income Eligibility Form For Child Care Centers
ADVERTISEMENT
1
2INCOME ELIGIBILITY FORM
for Child Care Centers
See INSTRUCTIONS on reverse.
CHILD CARE CENTER NAME:
Print the name of the child(ren) enrolled in this child care center:
1.
2.
3.
DIRECTIONS:
Complete SECTION B if no one in your household receives
Complete SECTION A if anyone in your household:
Food Stamps, TANF, FDPIR or if none of the children enrolled
1. Receives Food Stamps
in the child care center is a foster child.
2. Receives Temporary Assistance to Needy Families (TANF)
3. Participates in the Food Distribution Program on Indian
Reservations (FDPIR) OR
4. If any of the children enrolled in this child care center are
foster children
SECTION A
SECTION B
List all household members below. Include yourself and all
Food Stamp Case Number
adults and children NOT listed above, even if they do not
receive income. Then list all income received last month in
TANF Number
your household in the column to the right. Gross income
includes: earnings from work, pensions, retirement, Social
FDPIR Number
Security, child support, foster child's personal income and any
other sources of income.
Names of
Foster Children
Name of Household Members
Monthly Gross Income
An adult household member must sign the application
1.
$
before it can be approved. After reading the following
statement and the statement on the back, sign below.
2.
$
I certify that the above information is true. I understand that
the center will get Federal funds based on the information I
3.
$
give.
4.
$
Signature:
5.
$
Date:
6.
$
FOR SPONSOR USE ONLY
An adult household member must sign the application
Sponsor Agreement Number ____________
before it can be approved. After reading the following
statement and the statement on the back, sign below.
Total Household Members ____________
I certify that the above information is true and that all income
(including foster children, if applicable)
is reported. I understand that the center will get Federal funds
Total Income $____________
based on the information I give.
Free _______
Reduced _______
Paid _______
Signature:
Date Determined _____ / _____ / _____
Print Name:
xxx
xx
Signature of
-
-__ __ __ __
SS#
Date:
Center Staff________________________________________
DOH-3688 (5/11)
PAGE 1 OF 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal