Pennsylvania Application for Subsidized Child Care (CY 868) Instructions

Check this box if the alternate contact names you have provided should remain active until you contact the ELRC to remove them.

Enter the applicant’s street address (house number and street name).

Enter the applicant’s apartment, unit, or suite number, if applicable.

Enter the city for the applicant’s home address.

Enter the state for the applicant’s home address.

Enter the ZIP code for the applicant’s home address.

Enter the date the applicant became a resident of Pennsylvania.

Enter the applicant's first name.

Enter the applicant's last name.

Enter the applicant's middle initial.

Check this box if you have assets over one-million dollars.

Check this box if you do not have assets over one-million dollars.

Check this box if you currently receive housing assistance.

Check this box if you do not currently receive housing assistance.

Check this box if you currently receive Supplemental Nutrition Assistance Program (SNAP) benefits.

Check this box if you do not currently receive Supplemental Nutrition Assistance Program (SNAP) benefits.

Check this box if you currently receive TANF cash assistance.

Check this box if you do not currently receive TANF cash assistance.

Check this box if you currently receive CHIP (Children's Health Insurance Program) benefits.

Check this box if you do not currently receive CHIP (Children's Health Insurance Program) benefits.

Check this box if you currently receive Medical Assistance.

Check this box if you do not currently receive Medical Assistance.

Check this box if you currently receive WIC benefits.

Check this box if you do not currently receive WIC benefits.

Check this box if you have received TANF cash benefits at any time within the last six months.

Check this box if you have not received TANF cash benefits within the last six months.

Enter the name of the other state where you received TANF cash assistance if you selected "If yes" and chose "Other state" (instead of PA). Fill only if 'TANF received in other state' is 'Yes'.

Check this box if you received TANF cash benefits in Pennsylvania (PA). Fill only if 'Received TANF cash within last six months - Yes' is 'Yes'.

Check this box if you received TANF cash benefits in a state other than Pennsylvania, and specify the state. Fill only if 'Received TANF cash within last six months - Yes' is 'Yes'.

Provide any additional details or explanations about the benefits you currently receive or have received within the last six months (such as amounts, dates, or notes).

Enter the time of day you are most available to receive a phone call.

Enter the name of the child who has an absent parent.

Provide the full name of the child who is learning English as a second language.

Check this box if any of the children are learning English as a second language.

Check this box if none of the children are learning English as a second language.

Enter the name of the child who attended a Head Start or Early Head Start program.

Check this box if any of the above children have attended a Head Start or Early Head Start program.

Check this box if none of the above children have attended a Head Start or Early Head Start program.

Provide the name of the child who has moved from one school district to another because their parent or guardian is a migrant worker.

Check this box if any of the children have moved from one school district to another because their parent or guardian is a migrant worker.

Check this box if none of the children have moved from one school district to another because their parent or guardian is a migrant worker.

Check this box if your child needs health insurance.

Check this box if your child does not need health insurance.

Enter the name of the child who was referred to PA Pre-K Counts from another health or mental health agency.

Check this box if any of the children have been referred to PA Pre-K Counts from another health or mental health agency.

Check this box if none of the children have been referred to PA Pre-K Counts from another health or mental health agency.

Check this box if you or your spouse/live-in parent of the child needing care pay child support or alimony to someone who does not live with you.

Check this box if you or your spouse/live-in parent of the child needing care do not pay child support or alimony to someone who does not live with you.

Check this box if you are concerned about your child's development.

Check this box if you are not concerned about your child's development.

Enter the email address where you can be reached.

Enter the place of employment or self-employment for the spouse or live-in parent of the child.

Check this box if the spouse or live-in parent of the child is currently employed.

Check this box if the spouse or live-in parent of the child is not currently employed.

Check this box if the spouse or live-in parent of the child is self-employed.

Check this box if the spouse or live-in parent of the child is not self-employed.

Check this box if the spouse or live-in parent of the child needs child care for the child while they are working.

Check this box if the spouse or live-in parent of the child does not need child care for the child while they are working.

Please provide the name of your employer or the place of your self-employment.

Check this box if you are employed.

Check this box if you are not employed.

Check this box if you are self-employed.

Check this box if you are not self-employed.

Check this box if you need child care while you are working.

Check this box if you do not need child care while you are working.

Check this box if you would like to enroll in a program to get your high school equivalency diploma (GED).

Check this box if you would not like to enroll in a program to get your high school equivalency diploma (GED).

Check this box if you would like to enroll in a job training program.

Check this box if you would not like to enroll in a job training program.

Enter the fifth additional child's first name, last name, and middle initial.

Provide the fifth additional child's date of birth.

Enter the fifth additional child's Social Security Number if desired.

Specify how the fifth additional child is related to you, the parent or caretaker.

Specify how the fifth additional child is related to the second adult, if applicable.

Enter the fifth additional child's sex as M for male or F for female.

Check this box if the fifth additional child identifies as Black or African American.

Check this box if the fifth additional child identifies as American Indian or Alaskan Native.

Check this box if the fifth additional child identifies as Asian.

Check this box if the fifth additional child identifies as Native Hawaiian or Pacific Islander.

Check this box if the fifth additional child identifies as White.

Check this box if the race of the fifth additional child is unknown.

Check this box if the fifth additional child identifies with a race not listed above.

Check this box if the fifth additional child identifies as Hispanic.

Check this box if the fifth additional child identifies as Non-Hispanic.

Enter the full name of the fifth child who needs child care services.

Check this box if Child 5 is a U.S. citizen or is in the United States lawfully.

Check this box if Child 5 is not a U.S. citizen and is not in the United States lawfully.

Check this box if Child 5 needs child care services on Monday.

Check this box if Child 5 needs child care services on Tuesday.

Check this box if Child 5 needs child care services on Wednesday.

Check this box if Child 5 needs child care services on Thursday.

Check this box if Child 5 needs child care services on Friday.

Check this box if Child 5 needs child care services on Saturday.

Check this box if Child 5 needs child care services on Sunday.

Enter the full name of the tenth child needing service.

Check this box if the fifth child listed (row 10) is a U.S. Citizen or is lawfully present in the U.S.

Check this box if the fifth child listed (row 10) is not a U.S. Citizen or is not lawfully present in the U.S.

Check this box if the fifth child listed (row 10) needs child care services on Monday.

Check this box if the fifth child listed (row 10) needs child care services on Tuesday.

Check this box if the fifth child listed (row 10) needs child care services on Wednesday.

Check this box if the fifth child listed (row 10) needs child care services on Thursday.

Check this box if the fifth child listed (row 10) needs child care services on Friday.

Check this box if the fifth child listed (row 10) needs child care services on Saturday.

Check this box if the fifth child listed (row 10) needs child care services on Sunday.

Enter the fifth household member’s first name, last name, and middle initial.

Enter the fifth household member’s date of birth.

Enter the fifth household member’s Social Security number if you choose to provide it.

Describe how the fifth household member is related to you.

State whether the fifth household member is related to the second adult and describe the relationship if applicable.

Enter the fifth household member’s sex (M or F).

Check this box if the fifth household member identifies as Black or African American.

Check this box if the fifth household member identifies as American Indian or Alaskan Native.

Check this box if the fifth household member identifies as Asian.

Check this box if the fifth household member identifies as Native Hawaiian or Pacific Islander.

Check this box if the fifth household member identifies as White.

Check this box if the fifth household member’s race is unknown or not provided.

Check this box if the fifth household member identifies with a race not listed and you want to mark it as Other.

Check this box if the fifth household member’s ethnicity is Hispanic.

Check this box if the fifth household member’s ethnicity is Non-Hispanic.

Check this box if the first additional child is Hispanic.

Check this box if the first additional child is not Hispanic.

Check this box if the first additional child is Black or African American.

Check this box if the first additional child is American Indian or Alaskan Native.

Check this box if the first additional child is Asian.

Check this box if the first additional child is Native Hawaiian or Pacific Islander.

Check this box if the first additional child is White.

Check this box if the ethnicity of the first additional child is unknown.

Check this box if the ethnicity of the first additional child is not listed among the other options.

Enter the full name of the first alternate contact person.

Enter the telephone number of the first alternate contact person.

Enter the relationship of the first alternate contact person to you.

Enter the full name of the first child who needs child care services.

Check this box if Child 1 is a U.S. citizen or is in the United States lawfully.

Check this box if Child 1 is not a U.S. citizen and is not in the United States lawfully.

Check this box if you need child care services for Child 1 on Mondays.

Check this box if you need child care services for Child 1 on Tuesdays.

Check this box if you need child care services for Child 1 on Wednesdays.

Check this box if you need child care services for Child 1 on Thursdays.

Check this box if you need child care services for Child 1 on Fridays.

Check this box if you need child care services for Child 1 on Saturdays.

Check this box if you need child care services for Child 1 on Sundays.

Enter the full name of the first child needing service.

Check this box if the first child listed needs services and is a U.S. Citizen or is lawfully present in the U.S.

Check this box if the first child listed needs services and is not a U.S. Citizen and is not lawfully present in the U.S.

Check this box if the first child listed needs childcare services on Monday.

Check this box if the first child listed needs childcare services on Tuesday.

Check this box if the first child listed needs childcare services on Wednesday.

Check this box if the first child listed needs childcare services on Thursday.

Check this box if the first child listed needs childcare services on Friday.

Check this box if the first child listed needs childcare services on Saturday.

Check this box if the first child listed needs childcare services on Sunday.

Enter this household member’s date of birth.

Enter this household member’s first name, last name, and middle initial.

Enter this household member’s sex (M or F).

Enter this household member’s Social Security number, if you choose to provide it.

Describe how this household member is related to you (for example, child, spouse, or parent).

State whether this household member is related to the second adult and describe the relationship if applicable.

Check this box if the first household member (you) is Hispanic.

Check this box if the first household member (you) is Non-Hispanic.

Check this box if the first household member (you) identifies as Black or African American.

Check this box if the first household member (you) identifies as American Indian/Alaskan Native.

Check this box if the first household member (you) identifies as Asian.

Check this box if the first household member (you) identifies as Native Hawaiian/Pacific Islander.

Check this box if the first household member (you) identifies as White.

Check this box if the first household member’s (you) race is unknown or not provided.

Check this box if the first household member (you) identifies with a race not listed in the other options.

Enter the full name of the person who receives this income.

Specify the type of income received.

Indicate how often this income is received.

Enter the total amount of income received.

Provide the date when this income was last received.

Enter the first name, last name, and middle initial for the fourth additional child.

Provide the birth date for the fourth additional child.

Enter the Social Security Number for the fourth additional child if available.

State how the fourth additional child is related to you.

State how the fourth additional child is related to the second adult.

Indicate the sex of the fourth additional child.

Check this box if the fourth child is Black or African American.

Check this box if the fourth child is American Indian or Alaskan Native.

Check this box if the fourth child is Asian.

Check this box if the fourth child is Native Hawaiian or Pacific Islander.

Check this box if the fourth child is White.

Check this box if the fourth child's race is unknown.

Check this box if the fourth child's race is not listed above.

Check this box if the fourth child is of Hispanic ethnicity.

Check this box if the fourth child is not of Hispanic ethnicity.

Enter the full name of the fourth child who needs child care services.

Check this box if Child 4 is a U.S. citizen or is lawfully in the United States.

Check this box if Child 4 is not a U.S. citizen and is not lawfully in the United States.

Check this box if Child 4 needs child care services on Mondays.

Check this box if Child 4 needs child care services on Tuesdays.

Check this box if Child 4 needs child care services on Wednesdays.

Check this box if Child 4 needs child care services on Thursdays.

Check this box if Child 4 needs child care services on Fridays.

Check this box if Child 4 needs child care services on Saturdays.

Check this box if Child 4 needs child care services on Sundays.

Provide the full name of the fourth child needing service from this list.

Check this box if the fourth child needing service is a U.S. Citizen or is in the U.S. lawfully.

Check this box if the fourth child needing service is not a U.S. Citizen and is not in the U.S. lawfully.

Check this box if the fourth child needing service requires child care on Monday.

Check this box if the fourth child needing service requires child care on Tuesday.

Check this box if the fourth child needing service requires child care on Wednesday.

Check this box if the fourth child needing service requires child care on Thursday.

Check this box if the fourth child needing service requires child care on Friday.

Check this box if the fourth child needing service requires child care on Saturday.

Check this box if the fourth child needing service requires child care on Sunday.

Enter the fourth household member’s first name, last name, and middle initial.

Enter the fourth household member’s date of birth.

Enter the fourth household member’s Social Security number, if you choose to provide it.

Describe how the fourth household member is related to you (for example, child, spouse, or other relationship).

State whether the fourth household member is related to the second adult and describe the relationship.

Enter the fourth household member’s sex (M or F).

Check this box if the fourth household member’s race is Black or African American.

Check this box if the fourth household member’s race is American Indian/Alaskan Native.

Check this box if the fourth household member’s race is Asian.

Check this box if the fourth household member’s race is Native Hawaiian/Pacific Islander.

Check this box if the fourth household member’s race is White.

Check this box if the fourth household member’s race is unknown.

Check this box if the fourth household member’s race is not listed and should be marked as Other.

Check this box if the fourth household member’s ethnicity is Hispanic.

Check this box if the fourth household member’s ethnicity is Non-Hispanic.

Enter the location or method where you can receive information if you do not have a permanent address (for example, a shelter address, a trusted contact’s address, or ELRC pickup instructions). Fill only if 'Experiencing homelessness' is 'Yes'.

Check this box if you are experiencing homelessness, living in a shelter or transitional housing, or sharing housing because you cannot afford your own housing.

Check this box to certify that your child(ren) do not have age-appropriate immunizations.

Check this box if the immunization exemption is due to religious beliefs.

Check this box if the immunization exemption is due to a medical condition of the child.

Enter the name(s) of the child(ren) who have received their age-appropriate immunizations.

Check this box if you certify that your child(ren) listed below have received their age-appropriate immunizations (shots).

Check this box if anyone in your home receives income.

Check this box if no one in your home receives any income.

Check this box if anyone in the household receives income from wages.

Check this box if anyone in the household receives income from Social Security benefits.

Check this box if anyone in the household receives income from alimony.

Check this box if anyone in the household receives income from Supplemental Security Income (SSI).

Check this box if anyone in the household receives income from providing room and board.

Check this box if anyone in the household receives income from union pay or benefits.

Check this box if anyone in the household receives income from rent.

Check this box if anyone in the household receives income from Workers' Compensation.

Check this box if anyone in the household receives income from interest.

Check this box if anyone in the household receives income from unemployment compensation.

Check this box if anyone in the household receives income from spousal support.

Check this box if anyone in the household receives income from child support.

Check this box if anyone in the household receives income from commissions.

Check this box if you would like to receive information about a child's developmental stages.

Check this box if you do not want to receive information about a child's developmental stages.

Check this box if you would like to receive information about Early Head Start or Head Start programs.

Check this box if you do not want to receive information about Early Head Start or Head Start programs.

Check this box if you would like information about the Earned Income Tax Credit (EITC).

Check this box if you would not like information about the Earned Income Tax Credit (EITC).

Check this box if you would like information about free and reduced school meals.

Check this box if you do not want information about free and reduced school meals.

Check this box if you would like information about high quality child care and Keystone STARS.

Check this box if you do not want information about high quality child care and Keystone STARS.

Check this box if you would like to receive information about Pennsylvania's Home Visiting Programs.

Check this box if you do not want to receive information about Pennsylvania's Home Visiting Programs.

Check this box if you would like to receive information about Pre-K Counts.

Check this box if you do not want to receive information about Pre-K Counts.

Check this box if you would like information on Pennsylvania's supplemental food program for Women, Infants, and Children (WIC).

Check this box if you do not want information on Pennsylvania's supplemental food program for Women, Infants, and Children (WIC).

Enter the primary language spoken in your home.

Enter the primary language you read in your home.

Enter the language you would like to receive information in.

Check this box if you or your spouse/live-in parent of the child needing care have medical expenses that were not paid by insurance within the past 90 days and are expected to continue for the next six months.

Check this box if you or your spouse/live-in parent of the child needing care do not have medical expenses that were not paid by insurance within the past 90 days or are not expected to continue for the next six months.

Check this box if you are not a veteran and have not served in the military.

Check this box if you are a veteran of the U.S. military.

Check this box if you are currently serving on active duty in the military.

Check this box if you currently serve in the National Guard or military Reserves.

Check this box if you need dental or vision care.

Check this box if you do not need dental or vision care.

Check this box if you need health insurance.

Check this box if you do not need health insurance.

Check this box if you need help finding a quality child care program to meet the needs of your child and family.

Check this box if you do not need help finding a quality child care program.

Check this box if you need help paying for food (SNAP).

Check this box if you do not need help paying for food (SNAP).

Check this box if you need help paying for your heating, electric, or gas bills through programs like LIHEAP.

Check this box if you do not need help paying for your heating, electric, or gas bills.

Check this box if you need information about housing or rental assistance.

Check this box if you do not need information about housing or rental assistance.

Enter the type of income if it is not listed among the provided options.

Check this box if the type of income received is not listed among the other options provided on the form.

Enter the date the first parent or caretaker signed the document.

Enter the date the second parent or caretaker signed the document.

Check this box if you give permission to share your application and documents with early learning programs to determine eligibility for their services.

Check this box if you do not give permission to share your application with other early learning programs.

Check this box if you prefer to be called on your cell phone when there are questions.

Check this box if you prefer to be called on your home phone when there are questions.

Check this box if you prefer to be called at your work phone when there are questions.

Enter the full name of the second additional child, including first name, last name, and middle initial.

Enter the date of birth for the second additional child.

Enter the optional Social Security Number for the second additional child.

Enter how the second additional child is related to you.

Enter how the second additional child is related to the second adult.

Enter the sex of the second additional child.

Check this box if the second additional child is Black or African American.

Check this box if the second additional child is American Indian or Alaskan Native.

Check this box if the second additional child is Asian.

Check this box if the second additional child is Native Hawaiian or Pacific Islander.

Check this box if the second additional child is White.

Check this box if the second additional child's race is unknown.

Check this box if the second additional child's race is not listed.

Check this box if the second additional child is of Hispanic ethnicity.

Check this box if the second additional child is of Non-Hispanic ethnicity.

Enter the full name of the second alternate contact person.

Enter the telephone number for the second alternate contact person.

Enter the relationship of the second alternate contact person to you.

Enter the full name of the second child in your household who needs child care or early learning services.

Check this box if the second child needing care is a U.S. citizen or is in the United States lawfully.

Check this box if the second child needing care is not a U.S. citizen and is not in the United States lawfully.

Check this box if child care services are needed for the second child on Monday.

Check this box if child care services are needed for the second child on Tuesday.

Check this box if child care services are needed for the second child on Wednesday.

Check this box if child care services are needed for the second child on Thursday.

Check this box if child care services are needed for the second child on Friday.

Check this box if child care services are needed for the second child on Saturday.

Check this box if child care services are needed for the second child on Sunday.

Provide the full name of the seventh child needing service.

Check this box if the second child needing service is a U.S. Citizen or is in the U.S. lawfully.

Check this box if the second child needing service is not a U.S. Citizen or is not in the U.S. lawfully.

Check this box if the second child needing service requires child care services on Monday.

Check this box if the second child needing service requires child care services on Tuesday.

Check this box if the second child needing service requires child care services on Wednesday.

Check this box if the second child needing service requires child care services on Thursday.

Check this box if the second child needing service requires child care services on Friday.

Check this box if the second child needing service requires child care services on Saturday.

Check this box if the second child needing service requires child care services on Sunday.

Enter the second household member’s first name, last name, and middle initial.

Enter the second household member’s date of birth.

Enter the second household member’s sex as M or F.

Enter the second household member’s Social Security number, if you choose to provide it.

Describe how the second household member is related to you (for example, spouse, child, sibling).

State whether this person is related to the second adult and describe the relationship.

Check this box if the second household member’s ethnicity is Hispanic.

Check this box if the second household member’s ethnicity is Non-Hispanic.

Check this box if the second household member identifies as Black or African American.

Check this box if the second household member identifies as American Indian or Alaskan Native.

Check this box if the second household member identifies as Asian.

Check this box if the second household member identifies as Native Hawaiian or Pacific Islander.

Check this box if the second household member identifies as White.

Check this box if the second household member’s race is unknown or not provided.

Check this box if the second household member identifies with a race not listed and you want to select “Other.”

Enter the name of the person who receives this second income.

Specify the type or source of this second income.

Indicate how often this second income is received.

Enter the total amount of this second income received.

Provide the date when this second income was last received.

Enter the seventh household member’s first name, last name, and middle initial.

Enter the seventh household member’s date of birth.

Enter the seventh household member’s Social Security number if you choose to provide it.

Describe how the seventh household member is related to you.

State whether and how the seventh household member is related to the second adult listed on the form.

Enter the seventh household member’s sex (M or F).

Check this box if the seventh household member identifies as Black or African American.

Check this box if the seventh household member identifies as American Indian/Alaskan Native.

Check this box if the seventh household member identifies as Asian.

Check this box if the seventh household member identifies as Native Hawaiian/Pacific Islander.

Check this box if the seventh household member identifies as White.

Check this box if the seventh household member’s race is unknown.

Check this box if the seventh household member identifies with a race not listed (Other).

Check this box if the seventh household member’s ethnicity is Hispanic (select only one ethnicity option).

Check this box if the seventh household member’s ethnicity is Non-Hispanic (select only one ethnicity option).

Enter the sixth household member's first name, last name, and middle initial.

Enter the sixth household member's date of birth.

Enter the sixth household member's Social Security number, if you choose to provide it.

Describe how the sixth household member is related to you (for example, child, spouse, or parent).

State whether and how the sixth household member is related to the second adult listed on the form.

Enter the sixth household member's sex (M or F).

Check this box if the sixth household member identifies as Black or African American.

Check this box if the sixth household member identifies as American Indian or Alaskan Native.

Check this box if the sixth household member identifies as Asian.

Check this box if the sixth household member identifies as Native Hawaiian or Pacific Islander.

Check this box if the sixth household member identifies as White.

Check this box if the sixth household member’s race is unknown.

Check this box if the sixth household member identifies with a race not listed (or another race category).

Check this box if the sixth household member’s ethnicity is Hispanic.

Check this box if the sixth household member’s ethnicity is Non-Hispanic.

Check this box if you would like to take classes to learn English as a second language (ESL).

Check this box if you would not like to take classes to learn English as a second language (ESL).

Provide any relevant identifier or information regarding the teen parent for education purposes.

Check this box if you are a teen parent currently enrolled in elementary school, middle school, high school, or a GED program.

Check this box if you are a teen parent who needs child care while attending your education program.

Check this box if you are a teen parent not currently enrolled in elementary school, middle school, high school, or a GED program.

Check this box if you are a teen parent who does not need child care while attending your education program.

Enter your cell/mobile telephone number.

Enter your home telephone number.

Enter your work telephone number.

Enter the full name (first, last, and middle initial) of the third additional child.

Enter the date of birth for the third additional child.

Enter the optional Social Security Number for the third additional child.

Enter how the third additional child is related to you.

Enter how the third additional child is related to the second adult.

Enter the sex (M for Male or F for Female) of the third additional child.

Check this box if the third additional child is Black or African American.

Check this box if the third additional child is American Indian or Alaskan Native.

Check this box if the third additional child is Asian.

Check this box if the third additional child is Native Hawaiian or Pacific Islander.

Check this box if the third additional child is White.

Check this box if the ethnicity of the third additional child is unknown.

Check this box if the third additional child's ethnicity is not listed.

Check this box if the third additional child is of Hispanic origin.

Check this box if the third additional child is not of Hispanic origin.

Enter the full name of the third child who needs child care or early learning services.

Check this box if the third child listed is a U.S. citizen or is in the United States lawfully and admitted for permanent residence.

Check this box if the third child listed is not a U.S. citizen and is not in the United States lawfully and admitted for permanent residence.

Check this box if the third child needs child care services on Monday.

Check this box if the third child needs child care services on Tuesday.

Check this box if the third child needs child care services on Wednesday.

Check this box if the third child needs child care services on Thursday.

Check this box if the third child needs child care services on Friday.

Check this box if the third child needs child care services on Saturday.

Check this box if the third child needs child care services on Sunday.

Enter the full name of the third child needing service.

Check if the third child listed is a U.S. Citizen or is lawfully in the U.S.

Check if the third child listed is not a U.S. Citizen and is not lawfully in the U.S.

Check if the third child listed needs child care services on Monday.

Check if the third child listed needs child care services on Tuesday.

Check if the third child listed needs child care services on Wednesday.

Check if the third child listed needs child care services on Thursday.

Check if the third child listed needs child care services on Friday.

Check if the third child listed needs child care services on Saturday.

Check if the third child listed needs child care services on Sunday.

Enter the third household member’s first name, last name, and middle initial.

Enter the third household member’s date of birth.

Enter the third household member’s Social Security number, if you choose to provide it.

Describe how the third household member is related to you.

State whether the third household member is related to the second adult and describe the relationship if applicable.

Enter the third household member’s sex (M or F).

Check this box if the third household member identifies as Black or African American.

Check this box if the third household member identifies as American Indian or Alaskan Native.

Check this box if the third household member identifies as Asian.

Check this box if the third household member identifies as Native Hawaiian or Pacific Islander.

Check this box if the third household member identifies as White.

Check this box if the third household member’s race is unknown or not provided.

Check this box if the third household member’s race is not listed and should be marked as Other.

Check this box if the third household member’s ethnicity is Hispanic (select only one ethnicity option).

Check this box if the third household member’s ethnicity is Non-Hispanic (select only one ethnicity option).

Enter the name and location of the training program attended by the spouse or live-in parent of the child.

Check this box if the spouse or live-in parent of the child needs child care while attending their training program.

Check this box if the spouse or live-in parent of the child does not need child care while attending their training program.

Check this box if the spouse or live-in parent of the child is currently in a training program.

Check this box if the spouse or live-in parent of the child is not currently in a training program.

Provide the name and location of your training program.

Check this box if you require child care services while attending a training program.

Check this box if you do not require child care services while attending a training program.

Check this box if you are currently participating in a training program.

Check this box if you are not currently participating in a training program.

Check this box if you are not registered to vote where you live now and would like to apply to register to vote today.

Check this box if you are not registered to vote where you live now and would not like to apply to register to vote today.

Check this box if you are already registered to vote where you live now.