Section 2 Section 1 CHILD/ EMPLOYMENT - Welcome to …

1 CS-925 (FACE)REV. 5/07 PLEASE PRINT IN ALL CAPITAL LETTERSAPPLICATION FOR child CARE SUBSIDYCase #:OFFICE USE ONLYA pplication Date: _____ /_____ /_____LASTName (Please include any aliases or maiden names in parentheses): :ADDRESSR esidence:APT. #: CITY/BOROUGH:STATE: ZIP CODE:ADDRESSM ailing (if different than above):APT. #: CITY/BOROUGH:STATE: ZIP CODE:TELEPHONE(Work):TELEPHONE(Home):TEL EPHONE(Cell or Other):( ) _____( ) _____( ) _____Do you receive PA? YES NODo you receive Medicaid? YES NOWhat is your primary language?PA # : _____M A # : _____Please fill out the information below for your entire household.

2 List yourself first, followed by everyone who lives with American or Alaskan Native 2. Asian 3. African American/ Black 4. Native Hawaiian/Pacific Islander 5. Caucasian/ WhiteFor additional family members, please attach a separate USE ONLYI nclude information for any spouse/other parent of the children applying for care who lives in the Size: _____APPLICANT S EMPLOYERName:Hours per week:Tel #:( ) _____ADDRESS:CITY/BOROUGH: STATE:ZIP CODE:APPLICANT SScheduled Days and Hours of EMPLOYMENT ( : Mon Fri, 9 5 ):Does Job have a Rotation Shift? YES NODoes Job Require O/T? YES NOSPOUSE/OTHER PARENT EMPLOYERName:Hours per week:Tel #:( ) _____ADDRESS:CITY/BOROUGH: STATE:ZIP CODE:SPOUSE/OTHER PARENTS cheduled Days and Hours of EMPLOYMENT ( : Mon Fri, 9 5 ):Does Job have a Rotation Shift?

3 YES NODoes Job Require O/T? YES NOAC SnycNYC Administration for Children s Services NEW RECERTIFICATION TRANSITIONAL child CARES ection 1 APPLICANTS ection 2 FAMILY MEMBERSS ection 3 EMPLOYMENTS ection 4 CHILD/ FAMILYNEEDSLASTName(PLEASE INCLUDE ANY ALIASES ORMAIDEN NAMES IN PARENTHESES) THISPERSON NEEDCHILD CARE?YES/NOBOTH OF child SPARENTS RESIDEIN THE HOME?YES/NODATE OFBIRTHMM/DD/YYSEXM/FHISPANICORLATINOYES /NORACE(SEELEGENDBELOW)SOCIALSECURITYNUM BER(OPTIONAL)Are you requesting child care primarily so that you can work? YES NOIf not, please read the instruction Section titled CHILD/ Family Needs and write yourreason for care here:_____Is the child for whom you are requesting care living withsomeone other than his/her mother or father?

4 YES NODoes your child have any conditions that require special help or attention? YES NODoes your child have health insurance? YES NOOVER CS-925 (REVERSE)REV. 5/07 Please complete income information for yourself AND anyone applying with you. See instructions for documentation requirements.(This includes children in need of care, their parents, step-parent and any other children under the age of 18 in household.)PLEASE PRINTITEMGROSSTYPE OFOFFICE USE MONTHLYINCOMEDOCUMENTATIONCALCULATIONSAP PLICANT:Job earnings before deductions. weekly bi-weekly semi-monthly other$SPOUSE/OTHER PARENT:Job earnings before deductions. weekly bi-weekly semi-monthly otherFor all other income/ benefits please itemize below.

5 Include the amountFOR OFFICE USE ONLYfor yourself ANDyour spouse ANDchild(ren) who live with and/or child support. (Received) weekly bi-weekly semi-monthly otherUnemployment and/or worker s compensation. weekly bi-weekly semi-monthly otherNet income from self- EMPLOYMENT and/or rental income. weekly bi-weekly semi-monthly otherBENEFITS:Social Security, SSI, Disability, Retirement and/or Pensions & Annuities. weekly bi-weekly semi-monthly otherOTHER INCOME/BENEFITS(Check All That Apply): Cash or monetary assistance through the Temporary Assistance to Needy Families (TANF) program or Public Assistance (PA). Housing voucher or cash assistance.

6 Food stamps. Other federal cash income programs (such as SSI).TOTAL INCOME:$If your child is already in care, or you know the name of the program/provider where you plan to enroll your child , please list the provider name and address may list a second : _____N ame: _____N ame: _____Address: _____A ddress: _____A ddress: _____Please check the types of care that you would consider if there are no available slots with the provider(s) you listed above or if you do not have a provider in mind: Center Based Care Head Start Informal Care Family Day CareIs/are the CHILD/ children for whom you are applying a citizen(s)? YES NOIf Yes, Parent/Guardian must sign and date to certify that the CHILD/ children in receipt of child care assistance/subsidy _____ _____ /_____ /_____is/are a citizen(s).

7 PARENT/CARETAKER/WIFE/HUSBAND DATEIf No, your eligibility must be determined at the Resource Area ( ), please make an appointment at your and bring the documentation listed in the instructions for this SnycNYC Administration for Children s ServicesSection 5 OTHER INCOME EARNINGSS ection 6 PROVIDERS ection 7 CITIZEN-SHIPS ection 8 CERTIFICATIONPROGRAM #PROGRAM #PROGRAM # understand that the information contained on this form will be used to determine my ormy family s eligibility for services/subsidy and that the information will only be used forthe purposes of determining child care social security numbers (if provided)

8 Will not be released as they are confidential underfederal law and can be released/used only for the purposes specified in federal agree to inform the agency immediately of any change in my income, livingarrangement, household composition or address, where care is provided, who isproviding child care, provider fees, hours for which child care is needed, and that New York State Law and Federal Law provides that any applicant may be investigated forfine or jail or both, for a person found guilty of obtaining child care assistance/subsidyby concealing information or providing false understand that this application is used only for the expressed purpose of child caresubsidy.

9 To obtain other assistance such as Food Stamps, Medicaid, TemporaryAssistance, or other services, additional applications will be certify under the penalty of law that all the information I have supplied on this form istrue and provide the signature of the parent/caretaker who is applying for child care assistance or the signature of an authorized _____ /_____ /_____X_____ /_____ /_____SIGNATUREPARENT/CARETAKER/WIFE/HUS BANDDATESIGNATUREAUTHORIZED REPRESENTATIVEDATE_____PRINT NAMEPRINT NAMEE nrollmentApplicationCompletedby: _____ _____ _____ /_____ /_____Lengthof Eligibility:from: _____ /_____ /_____PRINT AND INITIALDATEACS EligibilityApprovedby: _____ _____ _____ /_____ /_____to: _____ /_____ /_____PRINT AND INITIALDATEP arent Fee:_____ _____ /_____ Verifiedby: _____ _____ /_____ /_____INITIALDATEPRINT AND INITIAL DATECODES: RFC: _____ PR: _____ FS: _____Section 9 OFFICEONLY