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Childcare Assistance Application
Step
1
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3
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Applicant Information
Applicant name (parent applying for services)
Gender
Male
Female
Other
Date of Birth
MM slash DD slash YYYY
Physical address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing address (if different from physical address)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
Phone
Are You a Teacher?
Yes
No
What School do you Teach at?
Marital Status
Single
Married
Separated
Divorced
Widowed
Race
Asian
American Indian/Alaskan Native
Black/African American
Hispanic Native Hawaiian/Other Pacific Islander
White
Other
Military Veteran
Yes
No
Active Duty
Yes
No
US Citizen
Yes
No
If no, please explain:
Household Information
How many people live in your household?
Please include applicant, 2nd parent (if applicable), and all children living in the home
Include 2nd parent information?
Yes
No
Complete the information for the 2nd Parent Residing in the home:
2nd Parent Name (only if resides in your household):
Gender
Male
Female
Other
Date of Birth
MM slash DD slash YYYY
Physical address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing address (if different from physical address)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
Phone
Marital status
Single
Married
Separated
Divorced
Widowed
Race
Asian
American Indian/Alaskan Native
Black/African American
Hispanic Native Hawaiian/Other Pacific Islander
White
Other
Military Veteran
Yes
No
Active Duty
Yes
No
US Citizen
Yes
No
If no, please explain:
Complete the following information for ALL CHILDREN RESIDING in the home:
Child Name
Gender
Male
Female
Other
Date of Birth
MM slash DD slash YYYY
Care requested for this child?
Yes
No
Type of Care Requested
Full Time- more than 6 hours per day
Part Time- less than 6 hours per day
Before/After School
US Citizen
Yes
No
If no, please explain:
Race
Asian
American Indian/Alaskan Native
Black/African American
Hispanic Native Hawaiian/Other Pacific Islander
White
Other
Does the child have a disability?
Yes
No
Applicant Relationship to Child
Parent
Adoptive Parent
Stepparent
Legal Guardian
Other
Documents Required
Proof of Age for each child needing care (provide one from this list)
Accepted file types: pdf, doc, docx, Max. file size: 128 MB.
Accepted Documents: Birth Certificate, Current US Passport, Hospital Record of Birth, Church of Baptismal Record, School Record/School ID Card, Immigration and Naturalization Service Records, Child Support Paternity Records, Public Assistance/Social Services Records, Adoption Papers or Records, Divorce or Court Custody Decrees, Native American Tribal Document
Employment—Training / Education
Please list ALL SOURCES of income and monthly gross amounts total for each source:
Income Type
Gross Amount
Applicant
Employer Name
Employer Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
Pay Frequency
Weekly
Bi-Weekly
Bi-Monthly
Monthly
Hourly Wage
Hours Per Week
Hire Date
MM slash DD slash YYYY
Highest Grade Level Completed
Applicant
Employer Name
Employer Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
Pay Frequency
Weekly
Bi-Weekly
Bi-Monthly
Monthly
Hourly Wage
Hours Per Week
Hire Date
MM slash DD slash YYYY
Highest Grade Level Completed
Please specify if you are requesting assistance for ONE, THREE, or SIX MONTHS and why you chose that time frame
Documents Required
Employment—Submit one of the following for each income source for Applicant and 2nd Parent, if applicable.
Drop files here or
Select files
Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 2.
Number of PAY STUBS to submit for the previous 3 months of employment if you are paid: Weekly = 13, Bi-weekly = 7, 2xMonthly = 6, Monthly = 3, Employment Verification Letter, Compensation Award Letter or Offer Letter, Workers Compensation Documentation/Statement, Award Letter from Veterans Affairs, SSDI Benefit Statement, Retirement/Pension Statement, Tax Return from Previous Year
Self-Employment Income—Verification of self-employment must be established prior to determining income. Please be prepared to submit:
Drop files here or
Select files
Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 3.
Documents required for the previous 3 months, IRS form 1040 Schedule D for Capital Gains, IRS form 1099-DIV, IRS form 1099-INT, for dividends or interest
If attending Training/Educational Program—Submit one of the following for the Applicant and 2nd Parent who is attending Training/Educational Program (skip if not attending):
Drop files here or
Select files
Accepted file types: pdf, doc, docx, Max. file size: 128 MB, Max. files: 3.
Transcript from education/training program listing credits in progress, Current Statement from education/training program provider, Tuition Statement with semester hours, Admission Letter including schedule and credit hours, Other Official Document from an education/training provider indicating current enrollment (Example: school schedule)
Other Assistance Currently Provided in Household
Please provide the child care provider(s) you have selected and verified they have space for your child(ren):
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Your ticket for the: Application Form
Title
Application Form
USD
