Pennsylvania Application for Subsidized Child Care (CY 868) Completed Form Examples and Samples
View clear, filled-out examples of the Pennsylvania Application for Subsidized Child Care (CY 868). Our detailed samples cover various scenarios to help you accurately complete your form and apply for child care assistance in PA.
Pennsylvania Subsidized Child Care (CY 868) Example: Single Parent Household
How this form was filled:
This is an example of a completed Pennsylvania Application for Subsidized Child Care (CY 868) for a single-parent household. The parent works full-time and attends part-time classes, requiring care for her two children. The form details the parent's employment and education schedules, household income including child support, and information for both children.
Information used to fill out the document:
- Application Date: 01/15/2026
- Parent/Caretaker Name: Emily Garcia
- Parent/Caretaker Date of Birth: 05/20/1996
- Parent/Caretaker SSN: 987-65-4321
- Household Address: 456 Pine Street, Harrisburg, PA 17101
- Phone Number: 717-555-0101
- Email Address: [email protected]
- Child 1 Name: Isabella Garcia
- Child 1 Date of Birth: 08/10/2017
- Child 2 Name: Leo Garcia
- Child 2 Date of Birth: 03/05/2022
- Household Status: Single Parent
- Parent's Activity 1 (Work): Full-time employment at The Daily Grind Cafe, 40 hours/week.
- Parent's Activity 2 (Education): Part-time student at Harrisburg Area Community College (HACC).
- Weekly Gross Income (Work): $600.00 ($15/hour * 40 hours)
- Other Income: Court-ordered child support ($400/month)
- Non-Custodial Parent Info: Provided; contributes child support.
- Requested Child Care Provider: Little Sprouts Early Learning Center
- Requested Care Schedule: Monday - Friday, 7:30 AM to 5:00 PM
What this filled form sample shows:
- Demonstrates how to fill out the form for a single-parent household.
- Includes both employment and education/training activities, a common scenario for applicants.
- Shows how to list multiple children with different ages and needs.
- Correctly reports various income sources, including wages and child support.
- Provides an example of how to include information for a non-household parent.
Form specifications and details:
| Use Case: | Single parent with two children, engaged in both work and an education/training program. |
| Form Name: | Pennsylvania Application for Subsidized Child Care |
| Form Number: | CY 868 |
| Jurisdiction: | Commonwealth of Pennsylvania, Department of Human Services |
Created: February 05, 2026 09:28 PM
