Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 10
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2944. Have you chosen a Child Care provider? ......................................................
Yes
No
Is this Child Care
Date child(ren)
provider licensed or
List the child(ren) being
began being
Name of Provider
a Family, Friend, or
cared for by this provider
cared for by this
Neighbor*?
provider
D34314000241029
*Read the Child Care Customer Education section if selecting a Family, Friend, or Neighbor.
45. For the children who need child care, do they have a disability or have a need for specialized
care? (ex: needs special equipment, assistance with feeding, etc.)?............
Yes
No
FOOD STAMP SECTION
46. Has anyone in your household been disqualified in any state from the Food Stamp program for a
program violation? ..........................................................................................
Yes
No
If yes, who? ___________________________________________ State: __________________
47. Has anyone in your household been sanctioned from the Food Stamp program due to non-
participation in Employment and Training requirements? ...................................................................
Yes
No
If yes, who? ___________________________________________________________________
If yes, does this person agree to participate? ...............................................................................
Yes
No
48. Is anyone in your household responsible for the care of a child under six? ........................................
Yes
No
If yes, who is caring for the child? _____________________ Name of child: ________________
49. Would it be a problem to obtain child care in order to participate in Employment and
Training activities? ...............................................................................................................................
Yes
No
If yes, explain: _________________________________________________________________
50. Is anyone in your household responsible to care for a disabled person for 20 hours or more
per week? ............................................................................................................................................
Yes
No
If yes, who? ___________________________________________________________________
51. Has anyone in your household been unemployed in the last six months? ..........................................
Yes
No
If yes, who? ___________________________________________________________________
52. Has anyone in your household been temporarily laid off? …...............................................................
Yes
No
If yes, explain: _________________________________________________________________
53. Is anyone in your household on strike? ...............................................................................................
Yes
No
If yes, who? ___________________________________________________________________
54. Is anyone in your household currently on probation or parole? ...........................................................
Yes
No
If yes, are they required to complete court ordered activities (Ex: work release or drug court)? ...
Yes
No
Who? _________________ What activities are required? _______________________________
55. Is anyone in your household participating in a drug/alcohol treatment program? ...............................
Yes
No
If yes, who? _______________________ Which program? ______________________________
56. Is anyone in your household participating in any of the following programs: Vocational Rehabilitation,
Older American programs, Easter Seals, Forestry program or Choose to Work? ...............................
Yes
No
If yes, who? ________________________ Which program? _____________________________
57. Is anyone in your household participating in refugee employment services? ......................................
Yes
No
If yes, who? ___________________________________________________________________
58. Is anyone in your household experiencing domestic violence? ...........................................................
Yes
No
If yes, who? ___________________________________________________________________
59. Is anyone in your household unable to access any type of public or private transportation? ….…...
Yes
No
If yes, explain: _________________________________________________________________
60. Does your household live more than 35 miles away from a DWS employment center? .....................
Yes
No
Page 10
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