This form contains 1264 fields organized into 53 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Child Care Provider Lists (Providers on Application + Other Providers)
You must complete a separate child care arrangement Section 4 (page 8) for each provider	Text
Child Care Providers on This Application (List)
Provider 1 — Name and Registration Number	Text	Enter the child care provider’s full name and registration number (if assigned) for the first provider on this application; include multiple provider names separated by commas or new lines. Fill only if 'More Than One Child Care Provider - Yes' is 'Yes'.
Family Size
List all other family members (not already listed in the application) counted in your family size	Text
Fifth Child Information
Fifth Child's Gender	Text	Enter the fifth child's gender (M for Male, F for Female).
Fifth Child's Date of Birth	Date	Enter the fifth child's date of birth.
Fifth Child's Last Name	Text	Enter the fifth child's last name.
Fifth Child's First Name	Text	Enter the fifth child's first name.
Yes	CheckBox
No	CheckBox
Yes	CheckBox
No	CheckBox
Fifth Child's Relationship to Client	Text	Enter the fifth child's relationship to the client.
Fifth Child's Social Security Number	Text	Enter the fifth child's social security number.
Fifth Child's Ethnic Origin Code 2	Text	Enter the second applicable ethnic origin code for the fifth child.
Fifth Child's Ethnic Origin Code 1	Text	Enter the first applicable ethnic origin code for the fifth child.
Fifth Other Family Member
5 FIRST NAME	Text
Fifth Other Family Member Social Security Number	Text	Enter the social security number for the fifth other family member.
Fifth Other Family Member Relationship to Applicant	Text	Enter the relationship of the fifth other family member to the applicant.
Fifth Other Family Member Date of Birth	Date	Enter the date of birth for the fifth other family member.
Fifth Other Family Member Last Name	Text	Enter the last name of the fifth other family member.
First Child Care Time Range
First Child's Age	Text	Enter the age of the first child whose child care schedule is being provided.
First Child Daily Rate
First Child Daily Rate	Number	Enter the daily rate for the first child.
First Child Friday Schedule
First Child Friday To PM	Checkbox	Check this box if the first child's child care schedule on Friday ends in the afternoon.
First Child Friday To AM	Checkbox	Check this box if the first child's child care schedule on Friday ends in the morning.
First Child Friday To Time	Time	Enter the time the first child's care ends on Friday.
First Child Friday From PM	Checkbox	Check this box if the first child's child care schedule on Friday begins in the afternoon.
First Child Friday From AM	Checkbox	Check this box if the first child's child care schedule on Friday begins in the morning.
First Child Friday From Time	Time	Enter the time the first child's care begins on Friday.
First Child Information
Social Security	Text
First Child's Social Security Number	Text	Enter the Social Security number of the first child.
First Child's Ethnic Origin	Text	Enter the ethnic origin of the first child.
First Child's Gender	Text	Enter the gender of the first child (Male/Female).
First Child's Date of Birth	Date	Enter the date of birth for the first child.
First Child's Last Name	Text	Enter the last name of the first child.
First Child's First Name	Text	Enter the first name of the first child.
First Child U.S. Citizen Yes	Checkbox	Check this box if the first child listed is a U.S. Citizen.
First Child U.S. Citizen No	Checkbox	Check this box if the first child listed is not a U.S. Citizen.
First Child Ward of State Yes	Checkbox	Check this box if the first child listed is a Ward of State.
First Child Ward of State No	Checkbox	Check this box if the first child listed is not a Ward of State.
First Child's Relationship to Client	Text	Enter the relationship of the first child to the client (applicant).
Sample Schedule of Hours in Child Care	Text
First Child Name	Text	Enter the full name of the first child receiving care.
First Child Relationship to Client	Text	Enter the relationship of the first child to the client (e.g., Son, Daughter, Grandchild).
First Child Monday Schedule
Sample Schedule of Hours in Child Care	Text
First Child Monday End Time	Time	Enter the time when child care ends for the first child on Monday.
First Child Monday From AM	Checkbox	Check this box if the first child's care on Monday begins in the AM.
First Child Monday From PM	Checkbox	Check this box if the first child's care on Monday begins in the PM.
First Child Monday To PM	Checkbox	Check this box if the first child's care on Monday ends in the PM.
First Child Monday To AM	Checkbox	Check this box if the first child's care on Monday ends in the AM.
First Child Multi-child Discount
First Child Multi-child Discount Explanation	Text	Provide a detailed explanation of the multi-child or family discount offered by the provider for the first child.
First Child Multi-child Discount Option	Text	Indicate whether the provider offers a multi-child or family discount for the first child by entering 'Yes' or 'No'.
First Child Multi-child Discount Yes	Checkbox	Check this box if the provider offers a multi-child or multi-family discount for the first child.
First Child Multi-child Discount No	Checkbox	Check this box if the provider does not offer a multi-child or multi-family discount for the first child.
First Child Saturday Schedule
First Child Saturday To PM	Checkbox	Check this box if the first child's care on Saturday ends in the afternoon.
First Child Saturday To AM	Checkbox	Check this box if the first child's care on Saturday ends in the morning.
First Child Saturday From PM	Checkbox	Check this box if the first child's care on Saturday starts in the afternoon.
First Child Saturday From AM	Checkbox	Check this box if the first child's care on Saturday starts in the morning.
First Child Saturday To Time	Time	Enter the time the first child's care ends on Saturday.
First Child Saturday From Time	Time	Enter the time the first child's care begins on Saturday.
First Child Schedule Variation
First Child Schedule Variation - Yes	Checkbox	Check this box if the first child's care schedule varies.
First Child Schedule Variation - No	Checkbox	Check this box if the first child's care schedule does not vary.
First Child Schedule Variation Explanation	Text	Provide a detailed explanation for the first child's varying child care schedule.
First Child School Attendance
First Child School Hours	Number	Enter the number of hours the first child spends in school.
First Child School Attendance: Yes	Checkbox	Check this box if the first child listed attends school.
First Child School Location
First Child School Is Not At Provider Location	Checkbox	Check this box if the first child's school is NOT located at the same place as the child care provider.
Does this child care schedule vary	Text
First Child Sunday Schedule
First Child Sunday To PM	Checkbox	Check this box if the first child's Sunday care ends in the afternoon.
First Child Sunday To AM	Checkbox	Check this box if the first child's Sunday care ends in the morning.
First Child Sunday From PM	Checkbox	Check this box if the first child's Sunday care starts in the afternoon.
First Child Sunday From AM	Checkbox	Check this box if the first child's Sunday care starts in the morning.
First Child Sunday End Time	Text	Provide the time the first child's Sunday care is scheduled to end.
First Child Sunday Start Time	Text	Provide the time the first child's Sunday care is scheduled to begin.
First Child Thursday Schedule
First Child Thursday TO PM	Checkbox	Check this box if the first child's care on Thursday ends in the PM.
First Child Thursday TO AM	Checkbox	Check this box if the first child's care on Thursday ends in the AM.
First Child Thursday FROM PM	Checkbox	Check this box if the first child's care on Thursday starts in the PM.
First Child Thursday FROM AM	Checkbox	Check this box if the first child's care on Thursday starts in the AM.
First Child Thursday To Time	Time	Please enter the time the first child's care ends on Thursday.
First Child Thursday From Time	Time	Please enter the time the first child's care begins on Thursday.
First Child Tuesday Schedule
First Child Tuesday TO PM	Checkbox	Check this box if the first child's care schedule on Tuesday ends in the afternoon.
First Child Tuesday TO AM	Checkbox	Check this box if the first child's care schedule on Tuesday ends in the morning.
First Child Tuesday FROM PM	Checkbox	Check this box if the first child's care schedule on Tuesday begins in the afternoon.
First Child Tuesday FROM AM	Checkbox	Check this box if the first child's care schedule on Tuesday begins in the morning.
First Child Tuesday To Time	Time	Enter the time the first child's care ends on Tuesday.
First Child Tuesday From Time	Time	Enter the time the first child's care begins on Tuesday.
First Child Wednesday Schedule
First Child Wednesday To PM	Checkbox	Check this box if the first child's usual child care schedule on Wednesday ends in the afternoon or evening.
First Child Wednesday To AM	Checkbox	Check this box if the first child's usual child care schedule on Wednesday ends in the morning.
First Child Wednesday From PM	Checkbox	Check this box if the first child's usual child care schedule on Wednesday starts in the afternoon or evening.
First Child Wednesday From AM	Checkbox	Check this box if the first child's usual child care schedule on Wednesday starts in the morning.
First Child Wednesday To Time	Time	Enter the time the first child's care ends on Wednesday.
First Child Wednesday From Time	Time	Enter the time the first child's care begins on Wednesday.
First Other Family Member
First Other Family Member Relationship to Applicant	Text	Please provide the relationship of the first other family member to the applicant.
First Other Family Member Social Security Number	Text	Please provide the social security number of the first other family member.
First Other Family Member First Name	Text	Please provide the first name of the first other family member.
First Other Family Member Last Name	Text	Please provide the last name of the first other family member.
First Other Family Member Date of Birth	Date	Please provide the date of birth of the first other family member.
Fourth Child Information
Fourth Child Gender	Text	Enter the gender of the fourth child, either 'M' for male or 'F' for female.
Fourth Child Date of Birth	Date	Enter the date of birth for the fourth child.
Fourth Child Last Name	Text	Enter the last name of the fourth child.
Fourth Child First Name	Text	Enter the first name of the fourth child.
Fourth Child U.S. Citizen Yes	Checkbox	Check this box if the fourth child is a U.S. Citizen.
Fourth Child U.S. Citizen No	Checkbox	Check this box if the fourth child is not a U.S. Citizen.
Fourth Child Ward of State Yes	Checkbox	Check this box if the fourth child is a Ward of State.
Fourth Child Ward of State No	Checkbox	Check this box if the fourth child is not a Ward of State.
Fourth Child Relationship to Client	Text	Enter the relationship of the fourth child to the client.
Fourth Child Social Security Number	Text	Enter the Social Security Number of the fourth child.
Fourth Child Ethnic Origin Part 2	Text	Enter the second part of the ethnic origin for the fourth child.
Fourth Child Ethnic Origin Part 1	Text	Enter the first part of the ethnic origin for the fourth child.
Fourth Other Family Member
Fourth Other Family Member Last Name	Text	Enter the last name of the fourth other family member.
Fourth Other Family Member First Name	Text	Enter the first name of the fourth other family member.
Fourth Other Family Member Social Security Number	Text	Enter the Social Security Number of the fourth other family member.
Fourth Other Family Member Relationship to Applicant	Text	Enter the relationship of the fourth other family member to the applicant.
Fourth Other Family Member Date of Birth	Date	Enter the date of birth for the fourth other family member.
General
WORK INFORMATION - If you are working more than one job, you MUST tell us about all your jobs even if you don't need child care for that job. Photocopy this page and complete a separate work information and work schedule section for each job you have	Text
Number of Jobs Currently Working	Number	Enter the total number of jobs you are currently working.
First Employer Company Name	Text	Enter the name of your first employer or company.
First Job Title	Text	Enter your job title for your first job.
First Job Address	Text	Enter the street address of your first employer.
First Job City	Text	Enter the city of your first employer.
First Job State	Text	Enter the state of your first employer.
First Job Zip Code	Text	Enter the zip code of your first employer.
First Job Work Telephone Number	Text	Enter the work telephone number for your first job, including the area code.
First Job Date Started	Date	Enter the date you started your first job.
I earn before deductions (complete one) per year	Text
I earn before deductions (complete one) per month	Text
I earn before deductions (complete one) Per hour	Text
First Job Earnings Per Hour	Number	Enter the amount you earn per hour before deductions for your first job.
per year	Text
First Job Earnings Per Year	Number	Enter the amount you earn per year before deductions for your first job.
First Job Earnings Per Month	Number	Enter the amount you earn per month before deductions for your first job.
First Job Pay Period Amount	Number	Enter the amount you get paid for your selected pay period (every day/every week) for your first job.
First Employer - Paid Every Week	Checkbox	Check this box if your first employer pays you every week.
First Employer - Paid Every Two Weeks	Checkbox	Check this box if your first employer pays you every two weeks.
First Employer - Paid Twice Per Month	Checkbox	Check this box if your first employer pays you twice per month.
First Employer - Paid Other (Explain)	Checkbox	Check this box if your first employer pays you on a schedule other than the options provided, and then explain the payment schedule.
First Job Weekly Hours	Number	Enter the number of hours you usually work each week for your first job.
First Job Weekly Days	Number	Enter the number of days you usually work each week for your first job.
First Employer - Paid Every Day	Checkbox	Check this box if your first employer pays you every day.
First Employer - Paid Once Per Month	Checkbox	Check this box if your first employer pays you once per month.
First Job Travel Time to Work	Text	Enter the estimated travel time from the child care provider to your first job.
First Job Monday From Time	Time	Enter the start time for your first job on Monday.
First Job Schedule Explanation	Text	If your first job schedule varies, explain how it varies.
FROM	Text
TO	Text
WORK SCHEDULE: If your schedule varies, provide an example of your schedule	Text
WORK SCHEDULE: If your schedule varies, provide an example of your schedule	Text
First Job Monday To Time	Time	Enter the end time for your first job on Monday.
First Job Tuesday From Time	Time	Enter the start time for your first job on Tuesday.
First Job Wednesday From Time	Time	Enter the start time for your first job on Wednesday.
First Job Thursday From Time	Time	Enter the start time for your first job on Thursday.
First Job Friday From Time	Time	Enter the start time for your first job on Friday.
First Job Saturday From Time	Time	Enter the start time for your first job on Saturday.
First Job Sunday From Time	Time	Enter the start time for your first job on Sunday.
TextField1	Text
First Job Tuesday To Time	Time	Enter the end time for your first job on Tuesday.
First Job Wednesday To Time	Time	Enter the end time for your first job on Wednesday.
First Job Thursday To Time	Time	Enter the end time for your first job on Thursday.
First Job Friday To Time	Time	Enter the end time for your first job on Friday.
First Job Saturday To Time	Time	Enter the end time for your first job on Saturday.
First Job Sunday To Time	Time	Enter the end time for your first job on Sunday.
WORK SCHEDULE: If your schedule varies, provide an example of your schedule	Text
WORK SCHEDULE: If your schedule varies, provide an example of your schedule	Text
WORK SCHEDULE: If your schedule varies, provide an example of your schedule	Text
WORK SCHEDULE: If your schedule varies, provide an example of your schedule	Text
WORK SCHEDULE: If your schedule varies, provide an example of your schedule	Text
Second Employer Company Name	Text	Enter the name of your second employer or company.
Second Job Title	Text	Enter your job title for your second job.
Second Job Address	Text	Enter the street address of your second employer.
Second Job City	Text	Enter the city of your second employer.
Second Job State	Text	Enter the state of your second employer.
Second Job Zip Code	Text	Enter the zip code of your second employer.
Second Job Work Telephone Number	Text	Enter the work telephone number for your second job, including the area code.
Second Job Date Started	Date	Enter the date you started your second job.
Second Employer	Text
Second Employer	Text
Second Job Earnings Per Hour	Number	Enter the amount you earn per hour before deductions for your second job.
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Job Pay Period Amount	Number	Enter the amount you get paid for your selected pay period (every day/every week) for your second job.
Second Employer - Paid Every Week	Checkbox	Check this box if your second employer pays you every week.
Second Employer - Paid Every Two Weeks	Checkbox	Check this box if your second employer pays you every two weeks.
Second Employer - Paid Twice Per Month	Checkbox	Check this box if your second employer pays you twice per month.
Second Employer - Paid Other (Explain)	Checkbox	Check this box if your second employer pays you on a schedule other than the options provided, and then explain the payment schedule.
Second Job Weekly Hours	Number	Enter the number of hours you usually work each week for your second job.
Second Job Weekly Days	Number	Enter the number of days you usually work each week for your second job.
Second Employer - Paid Every Day	Checkbox	Check this box if your second employer pays you every day.
Second Employer - Paid Once Per Month	Checkbox	Check this box if your second employer pays you once per month.
Second Job Earnings Per Year	Number	Enter the amount you earn per year before deductions for your second job.
Second Job Earnings Per Month	Number	Enter the amount you earn per month before deductions for your second job.
Second Job Monday From Time	Time	Enter the start time for your second job on Monday.
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Job Tuesday From Time	Time	Enter the start time for your second job on Tuesday.
Second Job Wednesday From Time	Time	Enter the start time for your second job on Wednesday.
Second Job Thursday From Time	Time	Enter the start time for your second job on Thursday.
Second Job Friday From Time	Time	Enter the start time for your second job on Friday.
Second Job Saturday From Time	Time	Enter the start time for your second job on Saturday.
Second Job Sunday From Time	Time	Enter the start time for your second job on Sunday.
Second Job Monday To Time	Time	Enter the end time for your second job on Monday.
Second Job Tuesday To Time	Time	Enter the end time for your second job on Tuesday.
Second Job Wednesday To Time	Time	Enter the end time for your second job on Wednesday.
Second Job Thursday To Time	Time	Enter the end time for your second job on Thursday.
Second Job Friday To Time	Time	Enter the end time for your second job on Friday.
Second Job Saturday To Time	Time	Enter the end time for your second job on Saturday.
Second Job Sunday To Time	Time	Enter the end time for your second job on Sunday.
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Job Schedule Explanation	Text	If your second job schedule varies, explain how it varies.
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Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
First Job Public Transportation	Text	Indicate whether you use public transportation for your first job by entering 'Yes' or 'No'.
Second Job Travel Time to Work	Text	Enter the estimated travel time from the child care provider to your second job.
Second Employer - Use Public Transportation Yes	Checkbox	Check this box if you use public transportation for travel to or from work for your second employer.
Second Employer - Use Public Transportation No	Checkbox	Check this box if you do not use public transportation for travel to or from work for your second employer.
Are you currently attending school, training or a TANF-Required Activity	Text
No (Go to Section 2 - Other Parent/Stepparent Information)	Checkbox	Check this box if you are not currently attending school, training, or a TANF-Required Activity.
Yes (Complete the information below.)	Checkbox	Check this box if you are currently attending school, training, or a TANF-Required Activity.
SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION	Text
TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)	Text
4-Year College Degree	Checkbox	Check this box if you are currently pursuing a 4-Year College Degree.
2-Year College Degree	Checkbox	Check this box if you are currently pursuing a 2-Year College Degree.
Occupational/Vocational	Checkbox	Check this box if you are currently attending an occupational or vocational training program.
Below Post - Secondary (e.g., ABE or ESL)	Checkbox	Check this box if you are currently attending an educational program below post-secondary level, such as ABE or ESL.
High School or GED	Checkbox	Check this box if you are currently attending high school or working towards a GED.
Type of Degree Being Earned	Text	Enter the type of degree you are currently earning.
SECTION 2 - OTHER PARENT/GUARDIAN/STEPPARENT INFORMATION	Text
Is the other parent or stepparent of any of your children, step children or wards living in your home	Text
No (Go to Section 3 - Family Information p. 6)	Checkbox	Check this box if the other parent or stepparent of any of your children, stepchildren or wards is not living in your home.
Yes (Complete the information below.)	Checkbox	Check this box if the other parent or stepparent of any of your children, stepchildren or wards is living in your home.
Please note: Information from various agencies' databases and internet web sites will be taken into consideration (See Question #6 on page 15). If the information does not match it may delay your eligibility. If the other parent or step parent could be listed on your case for other benefits TANF, SNAP/Food Stamps, Medical, Child Support Enforcement, Unemployment), but is no longer living with you, you may need to supply additional information to prove he/she is living somewhere else. If you cannot provide this documentation, please contact your local CCR&R or Site Administered child care provider	Text
OTHER PARENT/GUARDIAN/STEPPARENT INFORMATION	Text
Other Parent/Guardian/Stepparent Telephone Number	Text	Enter the telephone number of the other parent, guardian, or stepparent.
Other Parent/Guardian/Stepparent Date of Birth	Date	Enter the date of birth for the other parent, guardian, or stepparent.
Other Parent/Guardian/Stepparent Social Security Number	Text	Enter the Social Security Number of the other parent, guardian, or stepparent, if applicable.
Other Parent/Guardian/Stepparent Last Name	Text	Enter the last name of the other parent, guardian, or stepparent.
Other Parent/Guardian/Stepparent Middle Initial	Text	Enter the middle initial of the other parent, guardian, or stepparent.
Other Parent/Guardian/Stepparent First Name	Text	Enter the first name of the other parent, guardian, or stepparent.
Is the other parent or stepparent working	Text
Yes	Radiobutton	Check this box if the other parent or stepparent is currently working. 1
No	Radiobutton	Check this box if the other parent or stepparent is not currently working. 2
Yes	Radiobutton	Check this box if the other parent or stepparent is currently attending school or a training program. 3
No	Radiobutton	Check this box if the other parent or stepparent is not currently attending school or a training program. 4
Is the other parent or stepparent attending school or a training program	Text
Reason Cannot Care For Children	Text	Explain why the other parent or stepparent cannot care for the children if they are not working or attending a school/training program.
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Monday From Time	Time	Enter the start time for your Monday school or training schedule.
Tuesday From Time	Time	Enter the start time for your Tuesday school or training schedule.
Wednesday From Time	Time	Enter the start time for your Wednesday school or training schedule.
Thursday From Time	Time	Enter the start time for your Thursday school or training schedule.
Friday From Time	Time	Enter the start time for your Friday school or training schedule.
Saturday From Time	Time	Enter the start time for your Saturday school or training schedule.
Sunday From Time	Time	Enter the start time for your Sunday school or training schedule.
Monday To Time	Time	Enter the end time for your Monday school or training schedule.
Tuesday To Time	Time	Enter the end time for your Tuesday school or training schedule.
Wednesday To Time	Time	Enter the end time for your Wednesday school or training schedule.
Thursday To Time	Time	Enter the end time for your Thursday school or training schedule.
Friday To Time	Time	Enter the end time for your Friday school or training schedule.
Saturday To Time	Time	Enter the end time for your Saturday school or training schedule.
Sunday To Time	Time	Enter the end time for your Sunday school or training schedule.
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
SCHOOL SCHEDULE: Please complete the following schedule	Text
PM	CheckBox
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Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
Work Experience (TANF only)	Checkbox	Check this box if you are currently gaining work experience as part of a TANF program.
Highest Level of Education Completed	Text	Enter the highest level of education you have completed, such as a GED, high school diploma, trade school certificate, or BA degree.
School Zip Code	Text	Enter the zip code of the school or training program you are currently attending.
School State	Text	Enter the state of the school or training program you are currently attending.
School City	Text	Enter the city of the school or training program you are currently attending.
School Address	Text	Enter the street address of the school or training program you are currently attending.
Term End Date	Date	Enter the end date of the current term for your school or training program.
Term Start Date	Date	Enter the start date of the current term for your school or training program.
School Telephone Number	Text	Enter the telephone number of the school or training program you are currently attending.
School Name/Training Program	Text	Enter the name of the school or training program you are currently attending.
Travel Time to School	Text	Enter the estimated travel time from the child care provider to your school.
Yes	Checkbox	Check this box if you already have a professional license, degree, or certificate.
No	Checkbox	Check this box if you do not already have a professional license, degree, or certificate.
Professional License/Certificate Type	Text	If you have a professional license, degree, or certificate, specify its type.
Yes	Checkbox	Check this box if you use public transportation.
No	Checkbox	Check this box if you do not use public transportation.
Internship	Checkbox	Check this box if you are currently engaged in an internship.
WORK INFORMATION - If they are working more than one job, they MUST tell us about all their jobs even if they don't need child care for that job. Photocopy this page and complete a separate work information and work schedule section for each job they have	Text
Number of Jobs Currently Working	Text	Enter the total number of jobs currently held.
First Employer/Company Name	Text	Enter the name of the first employer or company.
First Job Title	Text	Enter the job title for the first employer.
First Employer Address	Text	Enter the street address of the first employer.
First Employer City	Text	Enter the city of the first employer.
First Employer State	Text	Enter the state of the first employer.
First Employer Zip Code	Text	Enter the zip code of the first employer.
First Employer Work Telephone Number	Text	Enter the work telephone number for the first employer, including the area code.
First Job Start Date	Date	Enter the date you started this job.
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First Job Hourly Earnings	Number	Enter the amount earned per hour before deductions for the first job.
First Job Monthly Earnings	Number	Enter the amount earned per month before deductions for the first job.
per year	Text
First Job Yearly Earnings	Number	Enter the amount earned per year before deductions for the first job.
per hour OR	Text
They get paid (check one)	Text
First Employer - Paid Every Week	Checkbox	Check this box if the first employer pays you every week.
First Employer - Paid Every Two Weeks	Checkbox	Check this box if the first employer pays you every two weeks.
First Employer - Paid Twice Per Month	Checkbox	Check this box if the first employer pays you twice per month.
First Employer - Paid Other Frequency	Checkbox	Check this box if the first employer pays you at a frequency not listed, and provide an explanation in the designated area.
First Job Weekly Hours	Number	Enter the number of hours usually worked at this job each week.
First Job Weekly Days	Number	Enter the number of days usually worked at this job each week.
First Employer - Paid Every Day	Checkbox	Check this box if the first employer pays you every day.
First Employer - Paid Once Per Month	Checkbox	Check this box if the first employer pays you once per month.
First Employer	Text
First Employer	Text
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First Job Monday From Time	Time	Enter the start time for Monday work hours.
First Job Tuesday From Time	Time	Enter the start time for Tuesday work hours.
First Job Wednesday From Time	Time	Enter the start time for Wednesday work hours.
First Job Thursday From Time	Time	Enter the start time for Thursday work hours.
First Job Friday From Time	Time	Enter the start time for Friday work hours.
First Job Saturday From Time	Time	Enter the start time for Saturday work hours.
First Job Sunday From Time	Time	Enter the start time for Sunday work hours.
First Job Monday To Time	Time	Enter the end time for Monday work hours.
First Job Tuesday To Time	Time	Enter the end time for Tuesday work hours.
First Job Wednesday To Time	Time	Enter the end time for Wednesday work hours.
First Job Thursday To Time	Time	Enter the end time for Thursday work hours.
First Job Friday To Time	Time	Enter the end time for Friday work hours.
First Job Saturday To Time	Time	Enter the end time for Saturday work hours.
First Job Sunday To Time	Time	Enter the end time for Sunday work hours.
First Employer	Text
First Employer	Text
First Employer	Text
First Employer	Text
First Employer	Text
First Job Schedule Explanation	Text	Explain how the work schedule varies for the first job.
Second Employer/Company Name	Text	Enter the name of the second employer or company.
Second Job Title	Text	Enter the job title for the second employer.
Second Employer Address	Text	Enter the street address of the second employer.
Second Employer City	Text	Enter the city of the second employer.
Second Employer State	Text	Enter the state of the second employer.
Second Employer Zip Code	Text	Enter the zip code of the second employer.
Second Employer Work Telephone Number	Text	Enter the work telephone number for the second employer, including the area code.
Second Job Start Date	Date	Enter the date you started this job.
Second Employer	Text
Second Employer	Text
Second Job Monthly Earnings	Number	Enter the amount earned per month before deductions for the second job.
Second Job Hourly Earnings	Number	Enter the amount earned per hour before deductions for the second job.
Second Employer	Text
Second Job Yearly Earnings	Number	Enter the amount earned per year before deductions for the second job.
Second Employer	Text
Second Employer	Text
Second Employer - Paid Every Week	Checkbox	Check this box if the second employer pays you every week.
Second Employer - Paid Every Two Weeks	Checkbox	Check this box if the second employer pays you every two weeks.
Second Employer - Paid Twice Per Month	Checkbox	Check this box if the second employer pays you twice per month.
Second Employer - Paid Other Frequency	Checkbox	Check this box if the second employer pays you at a frequency not listed, and provide an explanation in the designated area.
Second Job Weekly Hours	Number	Enter the number of hours usually worked at this job each week.
Second Job Weekly Days	Number	Enter the number of days usually worked at this job each week.
Second Employer - Paid Every Day	Checkbox	Check this box if the second employer pays you every day.
Second Employer - Paid Once Per Month	Checkbox	Check this box if the second employer pays you once per month.
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Job Monday From Time	Time	Enter the start time for Monday work hours for the second job.
Second Job Tuesday From Time	Time	Enter the start time for Tuesday work hours for the second job.
Second Job Wednesday From Time	Time	Enter the start time for Wednesday work hours for the second job.
Second Job Thursday From Time	Time	Enter the start time for Thursday work hours for the second job.
Second Job Friday From Time	Time	Enter the start time for Friday work hours for the second job.
Second Job Saturday From Time	Time	Enter the start time for Saturday work hours for the second job.
Second Job Sunday From Time	Time	Enter the start time for Sunday work hours for the second job.
Second Job Monday To Time	Time	Enter the end time for Monday work hours for the second job.
Second Job Tuesday To Time	Time	Enter the end time for Tuesday work hours for the second job.
Second Job Wednesday To Time	Time	Enter the end time for Wednesday work hours for the second job.
Second Job Thursday To Time	Time	Enter the end time for Thursday work hours for the second job.
Second Job Friday To Time	Time	Enter the end time for Friday work hours for the second job.
Second Job Saturday To Time	Time	Enter the end time for Saturday work hours for the second job.
Second Job Sunday To Time	Time	Enter the end time for Sunday work hours for the second job.
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Employer	Text
Second Job Schedule Explanation	Text	Explain how the work schedule varies for the second job.
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
First Job Travel Time	Text	Enter the estimated travel time from the child care provider to this job.
Second Job Travel Time	Text	Enter the estimated travel time from the child care provider to this job.
First Employer - Use Public Transportation Yes	Checkbox	Check this box if you use public transportation for travel time from the child care provider to your first employer.
First Employer - Use Public Transportation No	Checkbox	Check this box if you do not use public transportation for travel time from the child care provider to your first employer.
Second Employer - Use Public Transportation Yes	Checkbox	Check this box if you use public transportation for travel time from the child care provider to your second employer.
Second Employer - Use Public Transportation No	Checkbox	Check this box if you do not use public transportation for travel time from the child care provider to your second employer.
Is the other parent/guardian/stepparent currently attending school, training or a TANF - Required Activity	Text
No	Checkbox	Check this box if the other parent/guardian/stepparent is not currently attending school, training, or a TANF-Required Activity.
Yes	Checkbox	Check this box if the other parent/guardian/stepparent is currently attending school, training, or a TANF-Required Activity.
TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)	Text
4-Year College Degree	Checkbox	Check this box if the other parent/guardian/stepparent is currently pursuing a 4-Year College Degree.
2-Year College Degree	Checkbox	Check this box if the other parent/guardian/stepparent is currently pursuing a 2-Year College Degree.
Occupational/Vocational	Checkbox	Check this box if the other parent/guardian/stepparent is currently attending an Occupational/Vocational program.
Below Post-Secondary (e.g., ABE or ESL)	Checkbox	Check this box if the other parent/guardian/stepparent is currently attending a Below Post-Secondary education program, such as ABE or ESL.
High School or GED	Checkbox	Check this box if the other parent/guardian/stepparent is currently attending High School or pursuing a GED.
Type of Degree Being Earned	Text	Enter the type of degree currently being pursued or earned.
OTHER PARENT'S	Text
OTHER PARENT'S	Text
OTHER PARENT'S	Text
OTHER PARENT'S	Text
OTHER PARENT'S	Text
Tuesday From Time	Time	Enter the start time for Tuesday's schedule.
Wednesday From Time	Time	Enter the start time for Wednesday's schedule.
Thursday From Time	Time	Enter the start time for Thursday's schedule.
Friday From Time	Time	Enter the start time for Friday's schedule.
Saturday From Time	Time	Enter the start time for Saturday's schedule.
Sunday From Time	Time	Enter the start time for Sunday's schedule.
Monday To Time	Time	Enter the end time for Monday's schedule.
Tuesday To Time	Time	Enter the end time for Tuesday's schedule.
Wednesday To Time	Time	Enter the end time for Wednesday's schedule.
Thursday To Time	Time	Enter the end time for Thursday's schedule.
Friday To Time	Time	Enter the end time for Friday's schedule.
Saturday To Time	Time	Enter the end time for Saturday's schedule.
Sunday To Time	Time	Enter the end time for Sunday's schedule.
OTHER PARENT'S	Text
OTHER PARENT'S	Text
OTHER PARENT'S	Text
OTHER PARENT'S	Text
OTHER PARENT'S	Text
OTHER PARENT'S	Text
SECTION 3 - FAMILY INFORMATION	Text
Family size includes these people LIVING IN YOUR HOME: * You, * Your biological or adopted children under age 21. * The biological, step or adoptive parent of any of your children must be included. * Any other person related to you by blood or law for whom you provide more than 50% of their support (if you choose to include them and can verify their income) - for example an elderly parent or disabled person	Text
Family Size	Number	Enter the total number of people in your family size as defined in the description above this field.
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Parent/Guardian Name	Text	Provide the full name of the parent or guardian.
Work Experience (TANF only)	Checkbox	Check this box if the other parent/guardian/stepparent is currently engaged in Work Experience under TANF requirements.
Highest Level of Education Completed	Text	Enter the highest level of education completed, such as GED, High School Diploma, trade school certificate, or BA degree.
Zip Code	Text	Enter the zip code.
State	Text	Enter the state name or abbreviation.
City	Text	Enter the city name.
Street Address	Text	Enter the street address.
Term End Date	Date	Enter the end date of the school or training term.
Term Start Date	Date	Enter the start date of the school or training term.
Telephone Number	Text	Enter the telephone number.
School/Training Program Name	Text	Enter the name of the school or training program currently being attended.
Travel Time to School	Text	Enter the estimated travel time from the child care provider to the school.
OTHER PARENT'S SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION	Text
Yes	Checkbox	Check this box if the other parent/guardian/stepparent already possesses a professional license, degree, or certificate.
No	Checkbox	Check this box if the other parent/guardian/stepparent does not possess a professional license, degree, or certificate.
Type of Professional License/Certificate	Text	If applicable, specify the type of professional license, degree, or certificate held.
Internship	Checkbox	Check this box if the other parent/guardian/stepparent is currently participating in an Internship.
Yes	Checkbox	Check this box if the other parent/guardian/stepparent uses public transportation.
No	Checkbox	Check this box if the other parent/guardian/stepparent does not use public transportation.
Child 1 First Name	Text	Please provide the first name of the first child for whom you are requesting assistance.
Child 1 Last Name	Text	Please provide the last name of the first child for whom you are requesting assistance.
Child 1 Date of Birth	Date	Please provide the date of birth for the first child.
Child 1 Gender	Text	Please provide the gender of the first child (M for Male, F for Female).
Child 1 Ethnic Origin	Text	Please provide the ethnic origin code(s) for the first child, referring to the instructions at the bottom of the page.
U.S. Citizen	Text
Ward of State	Text
Child 2 First Name	Text	Please provide the first name of the second child for whom you are requesting assistance.
Child 2 Last Name	Text	Please provide the last name of the second child for whom you are requesting assistance.
U.S. Citizen	Text
Ward of State	Text
Child 3 First Name	Text	Please provide the first name of the third child for whom you are requesting assistance.
Child 3 Last Name	Text	Please provide the last name of the third child for whom you are requesting assistance.
U.S. Citizen	Text
Ward of State	Text
Child 4 First Name	Text	Please provide the first name of the fourth child for whom you are requesting assistance.
Child 4 Last Name	Text	Please provide the last name of the fourth child for whom you are requesting assistance.
U.S. Citizen	Text
Ward of State	Text
Child 5 First Name	Text	Please provide the first name of the fifth child for whom you are requesting assistance.
Child 5 Last Name	Text	Please provide the last name of the fifth child for whom you are requesting assistance.
U.S. Citizen	Text
Ward of State	Text
Parent/Guardian Name	Text	Please provide the full name of the parent or guardian completing this application.
For each child's Ethnic Origin, list all numbers below that apply: (Required for Federal Reporting) 1 - White 2 - Black or African American 3 - Hispanic or Latino (Persons declaring Hispanic ethnicity should also list their race, for example, "3-1", "3-2", "3-5") 4 - Asian 5 - American Indian or Alaskan Native 6 - Native Hawaiian - or Pacific Islander	Text
SOCIAL SECURITY NUMBER (Optional)	Text
Alien Registration Documentation	Text	Please provide your alien registration documentation details if any of the children are not U.S. citizens.
Social Security	Text
Child 2 Social Security Number	Text	Please provide the Social Security Number for the second child.
Child 2 Ethnic Origin	Text	Please provide the ethnic origin code(s) for the second child, referring to the instructions at the bottom of the page.
Social Security	Text
Child 3 Social Security Number	Text	Please provide the Social Security Number for the third child.
M/F	Text
Social Security	Text
Child 4 Social Security Number	Text	Please provide the Social Security Number for the fourth child.
M/F	Text
Social Security	Text
Child 5 Social Security Number	Text	Please provide the Social Security Number for the fifth child.
M/F	Text
Parent Guardian Name	Text	Enter the full name of the parent or guardian for this application.
SECTION 4 - CHILD CARE ARRANGEMENT	Text
List only the children who will be cared for by THIS child care provider. If your children go to school, pre-k, or head start at another facility during the day, list only the hours that they are in child care with THIS provider. For school age children, list only the hours they are in child care	Text
Does the child listed attend school	Text
Child 1 Daily Rate	Number	Enter the daily rate for child care for the first child.
Sample Schedule of Hours in Child Care	Text
Child 1 Monday From Time	Time	Enter the start time for child care on Monday for the first child.
Child 1 Monday To Time	Time	Enter the end time for child care on Monday for the first child.
Child 1 Age	Text	Enter the age of the first child.
Child 1 Name	Text	Enter the full name of the first child receiving care.
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Child 2 Schedule Variation Explanation	Text	If the second child's care schedule varies, provide a detailed explanation.
Usual Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Child 2 Monday From Time	Time	Enter the start time for child care on Monday for the second child.
Child 2 Monday To Time	Time	Enter the end time for child care on Monday for the second child.
Sample Schedule of Hours in Child Care	Text
Child 2 Name	Text	Enter the full name of the second child receiving care.
Tuesday To PM	Checkbox	Check this box if the child's usual care schedule ends in the PM on Tuesday.
Tuesday To AM	Checkbox	Check this box if the child's usual care schedule ends in the AM on Tuesday.
Tuesday From PM	Checkbox	Check this box if the child's usual care schedule begins in the PM on Tuesday.
Tuesday From AM	Checkbox	Check this box if the child's usual care schedule begins in the AM on Tuesday.
Sample Schedule of Hours in Child Care	Text
Wednesday To PM	Checkbox	Check this box if the child's usual care schedule ends in the PM on Wednesday.
Wednesday To AM	Checkbox	Check this box if the child's usual care schedule ends in the AM on Wednesday.
Wednesday From PM	Checkbox	Check this box if the child's usual care schedule begins in the PM on Wednesday.
Wednesday From AM	Checkbox	Check this box if the child's usual care schedule begins in the AM on Wednesday.
Thursday To PM	Checkbox	Check this box if the child's usual care schedule ends in the PM on Thursday.
Thursday To AM	Checkbox	Check this box if the child's usual care schedule ends in the AM on Thursday.
Thursday From PM	Checkbox	Check this box if the child's usual care schedule begins in the PM on Thursday.
Thursday From AM	Checkbox	Check this box if the child's usual care schedule begins in the AM on Thursday.
Sample Schedule of Hours in Child Care	Text
Saturday To PM	Checkbox	Check this box if the child's usual care schedule ends in the PM on Saturday.
Saturday To AM	Checkbox	Check this box if the child's usual care schedule ends in the AM on Saturday.
Saturday From PM	Checkbox	Check this box if the child's usual care schedule begins in the PM on Saturday.
Saturday From AM	Checkbox	Check this box if the child's usual care schedule begins in the AM on Saturday.
Sunday To PM	Checkbox	Check this box if the child's usual care schedule ends in the PM on Sunday.
Sunday To AM	Checkbox	Check this box if the child's usual care schedule ends in the AM on Sunday.
Sunday From PM	Checkbox	Check this box if the child's usual care schedule begins in the PM on Sunday.
Sunday From AM	Checkbox	Check this box if the child's usual care schedule begins in the AM on Sunday.
Child 2 Daily Rate	Number	Enter the daily rate for child care for the second child.
Friday To PM	Checkbox	Check this box if the child's usual care schedule ends in the PM on Friday.
Friday To AM	Checkbox	Check this box if the child's usual care schedule ends in the AM on Friday.
Friday From PM	Checkbox	Check this box if the child's usual care schedule begins in the PM on Friday.
Friday From AM	Checkbox	Check this box if the child's usual care schedule begins in the AM on Friday.
Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
No	CheckBox
School Hours 2	Text	Enter the hours the second child is in school.
Does the child listed attend school	Text
Yes	CheckBox
No	CheckBox
Year Round	CheckBox
Is the school at the same location as the provider	Text
Yes	CheckBox
No	CheckBox
Does this child care schedule vary	Text
Yes	CheckBox
No	CheckBox
Schedule Variation Explanation 2	Text	Provide an explanation if the second child's care schedule varies.
Discount Explanation 2	Text	Provide an explanation if the provider offers a multi-child/family discount for the second child.
Does the provider offer a multi-child/family discount	Text
Yes	CheckBox
No	CheckBox
Usual Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Daily Rate 1	Number	Enter the daily rate for the first child.
Sample Schedule of Hours in Child Care	Text
Monday Start Time 2	Time	Enter the time the second child's child care schedule starts on Monday.
Monday End Time 2	Time	Enter the time the second child's child care schedule ends on Monday.
Sample Schedule of Hours in Child Care	Text
Child's Age 2	Text	Enter the age of the second child.
Sample Schedule of Hours in Child Care	Text
Child's Name 2	Text	Enter the full name of the second child.
Sample Schedule of Hours in Child Care	Text
AM	CheckBox
PM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Tuesday End Time 2	Time	Enter the time the second child's child care schedule ends on Tuesday.
Tuesday Start Time 2	Time	Enter the time the second child's child care schedule starts on Tuesday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Wednesday End Time 2	Time	Enter the time the second child's child care schedule ends on Wednesday.
Wednesday Start Time 2	Time	Enter the time the second child's child care schedule starts on Wednesday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Thursday End Time 2	Time	Enter the time the second child's child care schedule ends on Thursday.
Thursday Start Time 2	Time	Enter the time the second child's child care schedule starts on Thursday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Saturday End Time 2	Time	Enter the time the second child's child care schedule ends on Saturday.
Saturday Start Time 2	Time	Enter the time the second child's child care schedule starts on Saturday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Sunday End Time 2	Time	Enter the time the second child's child care schedule ends on Sunday.
Sunday Start Time 2	Time	Enter the time the second child's child care schedule starts on Sunday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
Friday End Time 2	Time	Enter the time the second child's child care schedule ends on Friday.
PM	CheckBox
AM	CheckBox
Friday Start Time 2	Time	Enter the time the second child's child care schedule starts on Friday.
Sample Schedule of Hours in Child Care	Text
Daily Rate 2	Number	Enter the daily rate for the second child.
School Hours 3	Text	Enter the hours the third child is in school.
Does the child listed attend school	Text
Yes	CheckBox
No	CheckBox
Year Round	CheckBox
Is the school at the same location as the provider	Text
Yes	CheckBox
No	CheckBox
Usual Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Monday Start Time 3	Time	Enter the time the third child's child care schedule starts on Monday.
Monday End Time 3	Time	Enter the time the third child's child care schedule ends on Monday.
Sample Schedule of Hours in Child Care	Text
Child's Age 3	Text	Enter the age of the third child.
Sample Schedule of Hours in Child Care	Text
Child's Name 3	Text	Enter the full name of the third child.
Sample Schedule of Hours in Child Care	Text
AM	CheckBox
PM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Tuesday End Time 3	Time	Enter the time the third child's child care schedule ends on Tuesday.
Tuesday Start Time 3	Time	Enter the time the third child's child care schedule starts on Tuesday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Wednesday End Time 3	Time	Enter the time the third child's child care schedule ends on Wednesday.
Wednesday Start Time 3	Time	Enter the time the third child's child care schedule starts on Wednesday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Thursday End Time 3	Time	Enter the time the third child's child care schedule ends on Thursday.
Thursday Start Time 3	Time	Enter the time the third child's child care schedule starts on Thursday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Saturday End Time 3	Time	Enter the time the third child's child care schedule ends on Saturday.
Saturday Start Time 3	Time	Enter the time the third child's child care schedule starts on Saturday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Sunday End Time 3	Time	Enter the time the third child's child care schedule ends on Sunday.
Sunday Start Time 3	Time	Enter the time the third child's child care schedule starts on Sunday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
Friday End Time 3	Time	Enter the time the third child's child care schedule ends on Friday.
PM	CheckBox
AM	CheckBox
Friday Start Time 3	Time	Enter the time the third child's child care schedule starts on Friday.
Sample Schedule of Hours in Child Care	Text
Daily Rate 3	Number	Enter the daily rate for the third child.
Does this child care schedule vary	Text
Yes	CheckBox
Schedule Variation Explanation 3	Text	Provide an explanation if the third child's care schedule varies.
Discount Explanation 3	Text	Provide an explanation if the provider offers a multi-child/family discount for the third child.
Does the provider offer a multi-child/family discount	Text
Yes	CheckBox
No	CheckBox
School Hours 1	Text	Enter the hours the first child is in school.
Does the child listed attend school	Text
Yes	CheckBox
No	CheckBox
Year Round	CheckBox
Is the school at the same location as the provider	Text
Yes	CheckBox
No	CheckBox
Does this child care schedule vary	Text
Yes	CheckBox
No	CheckBox
Schedule Variation Explanation 1	Text	Provide an explanation if the first child's care schedule varies.
Discount Explanation 1	Text	Provide an explanation if the provider offers a multi-child/family discount for the first child.
Does the provider offer a multi-child/family discount	Text
Yes	CheckBox
No	CheckBox
Usual Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Monday Start Time 1	Time	Enter the time the first child's child care schedule starts on Monday.
Monday End Time 1	Time	Enter the time the first child's child care schedule ends on Monday.
Sample Schedule of Hours in Child Care	Text
Child's Age 1	Text	Enter the age of the first child.
Sample Schedule of Hours in Child Care	Text
Child's Name 1	Text	Enter the full name of the first child.
Sample Schedule of Hours in Child Care	Text
AM	CheckBox
PM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Tuesday End Time 1	Time	Enter the time the first child's child care schedule ends on Tuesday.
Tuesday Start Time 1	Time	Enter the time the first child's child care schedule starts on Tuesday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Wednesday End Time 1	Time	Enter the time the first child's child care schedule ends on Wednesday.
Wednesday Start Time 1	Time	Enter the time the first child's child care schedule starts on Wednesday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Thursday End Time 1	Time	Enter the time the first child's child care schedule ends on Thursday.
Thursday Start Time 1	Time	Enter the time the first child's child care schedule starts on Thursday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Saturday End Time 1	Time	Enter the time the first child's child care schedule ends on Saturday.
Saturday Start Time 1	Time	Enter the time the first child's child care schedule starts on Saturday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
PM	CheckBox
AM	CheckBox
Sunday End Time 1	Time	Enter the time the first child's child care schedule ends on Sunday.
Sunday Start Time 1	Time	Enter the time the first child's child care schedule starts on Sunday.
Sample Schedule of Hours in Child Care	Text
PM	CheckBox
AM	CheckBox
Friday End Time 1	Time	Enter the time the first child's child care schedule ends on Friday.
PM	CheckBox
AM	CheckBox
Friday Start Time 1	Time	Enter the time the first child's child care schedule starts on Friday.
Sample Schedule of Hours in Child Care	Text
Sample Schedule of Hours in Child Care	Text
Child's Relationship to Client 1	Text	Enter the first child's relationship to the client.
Child's Relationship to Client 2	Text	Enter the second child's relationship to the client.
Child's Relationship to Client 3	Text	Enter the third child's relationship to the client.
Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
TOTAL MONTHLY INCOME	Text
SECTION 5 - MONTHLY INCOME INFORMATION	Text
Enter the average gross MONTHLY income in each box for yourself and each member you have counted in your family size. Information from various agencies' databases and web sites will be taken into consideration when determining eligibility. If the Type of Monthly Income does not apply, write N/A	Text
Type of Monthly Income	Text
Applicant (YOU)	Text
Other Family Members	Text
Employment Income - Applicant	Number	Enter the average gross monthly employment income for the applicant (you).
Applicant (YOU)	Text
Employment Income - Other Family Members	Number	Enter the average gross monthly employment income for other family members.
Self Employment Income - Other Family Members	Number	Enter the average gross monthly self-employment income for other family members.
Self Employment Income - Applicant	Number	Enter the average gross monthly self-employment income for the applicant (you).
2. Self Employment Income for you and family member age 19 and older. Attach verification such as, most recent Federal tax return (IRS 1040 and all attachments), or a copy of quarterly estimated taxes, or a listing of all business income expenses for the last 30 days. This can be reported on your own form or a Self Employment form which can be downloaded at: http://www.dhs.state.il.us/OneNetLibrary/27897/documents/Forms/IL444-2790.pdf	Text
or requested from your local CCR&R. Receipts, invoices or other documentation must be attached	Text
Child Support Received - Other Family Members	Number	Enter the average gross monthly child support received by other family members.
Child Support Received - Applicant	Number	Enter the average gross monthly child support received by the applicant (you).
3. Child Support Received for all family members	Text
TANF Cash Assistance - Other Family Members	Number	Enter the average gross monthly TANF (Temporary Assistance for Needy Families) cash assistance received by other family members.
TANF Cash Assistance - Applicant	Number	Enter the average gross monthly TANF (Temporary Assistance for Needy Families) cash assistance received by the applicant (you).
4. TANF Cash Assistance for all family members	Text
Other Federal Cash Income - Other Family Members	Number	Enter the average gross monthly other federal cash income, such as Social Security or railroad benefits, received by other family members.
Other Federal Cash Income - Applicant	Number	Enter the average gross monthly other federal cash income, such as Social Security or railroad benefits, received by the applicant (you).
5. Other Federal Cash Income: for example, Social Security payments for ALL family members and railroad benefits	Text
Other Monthly Income - Other Family Members	Number	Enter the average gross monthly other income, such as unemployment, adoption assistance, disability, alimony, or pensions, received by other family members.
Other Monthly Income - Applicant	Number	Enter the average gross monthly other income, such as unemployment, adoption assistance, disability, alimony, or pensions, received by the applicant (you).
6. Other Monthly Income for all family members; for example - unemployment compensation, ongoing monthly adoption assistance payments from DCFS, permanent disability payments (SSI), alimony, interest income, royalties, pension, annuities, veteran's pension, survivor's benefits, and living expenses portion of educational grants	Text
Subtotal Income - Other Family Members	Number	Enter the calculated subtotal of all monthly income for other family members by adding lines 1 through 6.
Subtotal Income - Applicant	Number	Enter the calculated subtotal of all monthly income for the applicant (you) by adding lines 1 through 6.
SUBTOTAL (add lines 1 - 6)	Text
Other Family Members	Text
Applicant (YOU)	Text
SUBTRACT Child Support Paid by you or another family member	Text
Child Support Paid - Other Family Members	Number	Enter the amount of child support paid monthly by other family members.
Child Support Paid - Applicant	Number	Enter the amount of child support paid monthly by the applicant (you).
Total Monthly Income - Other Family Members	Number	Enter the calculated total monthly income for other family members.
Total Monthly Income - Applicant	Number	Enter the calculated total monthly income for the applicant (you).
If you receive any Housing Cash Assistance, including vouchers with a specific cash value, please report the amount here. This is required for Federal reporting only, and it DOES NOT COUNT IN TOTAL FAMILY INCOME	Text
Housing Cash Assistance	Number	Enter the amount of any housing cash assistance or vouchers received.
Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
CHILD CARE COLLABORATIONS	Text
SECTION 6 - CHILD CARE PROVIDER INFORMATION	Text
To be completed by the Provider (Please print clearly in blue or black ink)	Text
Parents or stepparents cannot be paid to provide child care for any children in the home. Providers must be at least 18 years of age and clear required background checks	Text
Date of Birth Year	Text	Enter the year of the child care provider's date of birth.
Date of Birth Day	Text	Enter the day of the child care provider's date of birth.
Date of Birth Month	Text	Enter the month of the child care provider's date of birth.
Date of Birth (MM/DD/YYYY) (Not required for Centers and Licensed Providers)	Text
Email	Text	Enter the email address of the child care provider.
Fax Number	Text	Enter the fax number of the child care provider, if applicable.
Phone Number	Text	Enter the phone number of the child care provider.
Mailing Address (If different)	Text	Enter the mailing address if it is different from the physical address provided above.
Zip Code	Text	Enter the five-digit zip code of the child care provider's address.
State	Text	Enter the state of the child care provider's address.
City	Text	Enter the city of the child care provider's address.
Street Address	Text	Enter the street address of the child care provider.
Day Care Center Corporate Name	Text	Enter the corporate name if the provider is a Day Care Center.
Name of Child Care Provider	Text	Enter the full legal name of the child care provider.
County	Text	Enter the county of the child care provider's address.
Provider Must Complete One: Note: Read the instructions included with the W-9 form for information on these options. If you have already registered as a provider for this program, list only your registration number	Text
Social Security Number	Text	Enter the Social Security Number if the provider is an individual or sole proprietor.
FEIN	Text	Enter the Federal Employer Identification Number if the provider is a corporation, partnership, or sole proprietor.
Government Unit Code	Text	Enter the Government Unit Code if the provider is a public school or park district.
IDHS Provider Registration Number	Text	Enter your IDHS Provider Registration Number if you are already registered as a provider for this program.
Child care providers are considered to be self-employed and taxes cannot be deducted from IDHS payments. This income is taxable and must be reported on tax documents. The Office of the Comptroller sends out a 1099 tax information form after each calendar year to all individual providers that earn $600 or more a calendar year	Text
Child Care Collaboration Head Start	Checkbox	Check this box if your IDHS approved Child Care Collaboration is a Head Start program.
Are you an IDHS approved Child Care Collaboration	Text
Check all that apply	Text
Child Care Collaboration ISBE Pre-K	Checkbox	Check this box if your IDHS approved Child Care Collaboration is an ISBE Pre-K program.
How long is your program	Text
Program Length 9 Months	Checkbox	Check this box if your program length is 9 months.
Program Length 12 Months	Checkbox	Check this box if your program length is 12 months.
Program Length Other	Checkbox	Check this box if your program length is other than 9 or 12 months.
Program Length (Other)	Text	Specify the duration of your program if it is not 9 or 12 months.
Have you been approved for the Illinois Quality Counts Quality Rating System (QRS)	Text
Approved for QRS Yes	Checkbox	Check this box if you have been approved for the Illinois Quality Counts Quality Rating System (QRS).
Approved for QRS No	Checkbox	Check this box if you have not been approved for the Illinois Quality Counts Quality Rating System (QRS).
Are you an employee of the Illinois Department of Human Services or any other State agency	Text
Employee of IDHS or Other State Agency No	Checkbox	Check this box if you are not an employee of the Illinois Department of Human Services or any other State agency.
Employee of IDHS or Other State Agency Yes	Checkbox	Check this box if you are an employee of the Illinois Department of Human Services or any other State agency.
Collaboration Child Details	Text	Provide details if any children in the family are enrolled as a collaboration child.
Child Care Start Date	Date	Enter the date the child care provider recently began or will begin caring for children.
IDHS Approved Child Care Collaboration Yes	Checkbox	Check this box if you are an IDHS approved Child Care Collaboration.
IDHS Approved Child Care Collaboration No	Checkbox	Check this box if you are not an IDHS approved Child Care Collaboration.
Convicted of Non-Minor Traffic Violation Yes	Checkbox	Check this box if you have ever been convicted of anything other than a minor traffic violation.
Convicted of Non-Minor Traffic Violation No	Checkbox	Check this box if you have never been convicted of anything other than a minor traffic violation.
Conviction Explanation	Text	Explain the nature of any conviction other than a minor traffic violation.
Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
FIRST NAME	Text
LAST NAME	Text
DATE OF BIRTH	Text
RELATIONSHIP TO PROVIDER	Text
SOCIAL SECURITY NUMBER	Text
Care by Non-Relative - In Provider's Home	Checkbox	Check this box if a non-relative provides child care in the non-relative's home.
Care by Non-Relative - In Child's Home	Checkbox	Check this box if a non-relative provides child care in the child's home.
CARE BY A NON-RELATIVE (LICENSE NOT REQUIRED)	Text
Care by Relative - In Child's Home	Checkbox	Check this box if a relative provides child care in the child's home.
Care by Relative - In Provider's Home	Checkbox	Check this box if a relative provides child care in the relative's home.
CARE BY A RELATIVE (LICENSE NOT REQUIRED)	Text
Relationship to Child(ren)	Text	Describe your relationship to the child or children.
Additional Language	Text	Specify any additional language not explicitly listed or selected.
Language - English	Checkbox	Check this box if English is the preferred language for communication.
Language - Spanish	Checkbox	Check this box if Spanish is the preferred language for communication.
Language - Polish	Checkbox	Check this box if Polish is the preferred language for communication.
Language - Chinese	Checkbox	Check this box if Chinese is the preferred language for communication.
Other Language	Text	Specify any other language not listed above.
NOT REQUIRED FOR LICENSED PROVIDERS If care is being provided in the home of the provider, list all other people living in the provider's home	Text
Day Care Licensing Information	Text	Provide any additional day care licensing information as required.
Licensed Group Day Care Home	Checkbox	Check this box if the child care is provided by a licensed group day care home.
LEGAL CARE ARRANGEMENT	Text
CENTERS AND LICENSED PROVIDERS DAY CARE LICENSING INFORMATION	Text
Licensed Day Care Center	Checkbox	Check this box if the child care is provided by a licensed day care center.
Day Care Center Exempt from Licensing	Checkbox	Check this box if the child care is provided by a day care center that is exempt from licensing.
Licensed Day Care Home	Checkbox	Check this box if the child care is provided by a licensed day care home.
(DO NOT enter a Foster Care License Number)	Text
License Number	Text	Enter the provider's license number.
License Capacity	Text
License Expiration	Date	Enter the date when the license expires.
Hours of Operation From (Hour)	Text	Enter the starting hour of operation.
License Capacity Day	Number	Enter the licensed capacity for day care.
License Capacity Night	Number	Enter the licensed capacity for night care.
Hours of Operation From (Minute)	Text	Enter the starting minute of operation.
Hours of Operation To (Hour)	Text	Enter the ending hour of operation.
Person 7 Social Security Number	Text	Enter the social security number for the seventh person living in the provider's home.
Person 7 Relationship to Provider	Text	Enter the relationship of the seventh person to the provider.
Person 7 Date of Birth	Date	Enter the date of birth for the seventh person living in the provider's home.
Person 7 Last Name	Text	Enter the last name of the seventh person living in the provider's home.
Person 7 First Name	Text	Enter the first name of the seventh person living in the provider's home.
Person 8 Social Security Number	Text	Enter the social security number for the eighth person living in the provider's home.
Person 8 Relationship to Provider	Text	Enter the relationship of the eighth person to the provider.
Person 8 Date of Birth	Date	Enter the date of birth for the eighth person living in the provider's home.
Person 8 Last Name	Text	Enter the last name of the eighth person living in the provider's home.
Person 8 First Name	Text	Enter the first name of the eighth person living in the provider's home.
Person 6 Social Security Number	Text	Enter the social security number for the sixth person living in the provider's home.
Person 6 Relationship to Provider	Text	Enter the relationship of the sixth person to the provider.
Person 6 Date of Birth	Date	Enter the date of birth for the sixth person living in the provider's home.
Person 6 Last Name	Text	Enter the last name of the sixth person living in the provider's home.
Person 6 First Name	Text	Enter the first name of the sixth person living in the provider's home.
Person 1 Social Security Number	Text	Enter the social security number for the first person living in the provider's home.
Person 1 Relationship to Provider	Text	Enter the relationship of the first person to the provider.
Person 1 Date of Birth	Date	Enter the date of birth for the first person living in the provider's home.
Person 1 Last Name	Text	Enter the last name of the first person living in the provider's home.
Person 1 First Name	Text	Enter the first name of the first person living in the provider's home.
Person 2 Social Security Number	Text	Enter the social security number for the second person living in the provider's home.
Person 2 Relationship to Provider	Text	Enter the relationship of the second person to the provider.
Person 2 Date of Birth	Date	Enter the date of birth for the second person living in the provider's home.
Person 2 Last Name	Text	Enter the last name of the second person living in the provider's home.
Person 2 First Name	Text	Enter the first name of the second person living in the provider's home.
Person 3 Social Security Number	Text	Enter the social security number for the third person living in the provider's home.
Person 3 Relationship to Provider	Text	Enter the relationship of the third person to the provider.
Person 3 Date of Birth	Date	Enter the date of birth for the third person living in the provider's home.
Person 3 Last Name	Text	Enter the last name of the third person living in the provider's home.
Person 3 First Name	Text	Enter the first name of the third person living in the provider's home.
Person 4 Social Security Number	Text	Enter the social security number for the fourth person living in the provider's home.
Person 4 Relationship to Provider	Text	Enter the relationship of the fourth person to the provider.
Person 4 Date of Birth	Date	Enter the date of birth for the fourth person living in the provider's home.
Person 4 Last Name	Text	Enter the last name of the fourth person living in the provider's home.
Person 4 First Name	Text	Enter the first name of the fourth person living in the provider's home.
Person 5 Social Security Number	Text	Enter the social security number for the fifth person living in the provider's home.
Person 5 Relationship to Provider	Text	Enter the relationship of the fifth person to the provider.
Person 5 Date of Birth	Date	Enter the date of birth for the fifth person living in the provider's home.
Person 5 Last Name	Text	Enter the last name of the fifth person living in the provider's home.
Person 5 First Name	Text	Enter the first name of the fifth person living in the provider's home.
Person 9 Social Security Number	Text	Enter the social security number for the ninth person living in the provider's home.
Person 9 Relationship to Provider	Text	Enter the relationship of the ninth person to the provider.
Person 9 Date of Birth	Date	Enter the date of birth for the ninth person living in the provider's home.
Person 9 Last Name	Text	Enter the last name of the ninth person living in the provider's home.
Person 9 First Name	Text	Enter the first name of the ninth person living in the provider's home.
Parent/Guardian Name	Text	Provide the full name of the parent or guardian.
After reading each of the following statements regarding child care standards, I certify that: * Parents will have unrestricted access to their children at all times. * All state and local fire, health and safety codes have been followed and will be maintained. * All child care providers/staff will have a physical examination no more than two years old and a TB skin test documented and on file in the facility/home within 90 days of the signature date on this form. The TB skin test is to be no earlier than the date the provider/staff began providing child care services. * All cleaning agents, poisons and other hazardous materials are stored in an area inaccessible to the child(ren). * There are no firearms or ammunition in the home OR any firearms or ammunition in the home are stored in a locked cabinet or locked storage at all times. * First aid supplies are readily available. * There will be no corporal punishment. * The children will be provided developmentally appropriate play and physical activities daily. * The children will be supervised (indoors and outdoors) at all times. * The children will be provided nutritional meals/snacks daily based on the number of hours in care. * I have not been responsible, and if I am a home provider, no one living in my household age 13 and older has been responsible, for the abuse or neglect of children or any acts of sexual molestation or sexual exploitation of children. I authorize the Dept. of Children and Family Services to check the Child Abuse and Neglect Tracking System (CANTS) and the Sex Offender Registry (SOR) to confirm this information for the Department of Human Services. * I and members of my household may need to complete an Authorization for Background Check form. If required, the CCR&R will mail this form with instructions on how to complete it. After reading each of the following statements regarding child care assistance program policies, I understand: * That if I am a home child care provider, I will report any new person(s) living in my household within 10 days. * The information provided will be checked using State databases. * I understand the information provided will be disclosed only for administrative purposes and that I may be required to verify the information, but is also subject to release under FOIA. * I cannot be paid until I complete a W-9 form and I am certified by the Office of the Comptroller. * I am responsible for collecting a co-payment from each family and that the co-payment will be deducted from the payment I receive from IDHS. * The State is required to make payment deductions for all home child care providers in accordance with the Service Employees International Union (SEIU) contract. * The State is not liable for payment of child care services provided prior to the date of an approval notice issued by the State. * If I am a child care center provider, licensed home, or group home, I will maintain, for a minimum of five (5) years from the date of payment, daily attendance records to fully document the extent of services provided and agree to make all records and supporting documentation relevant to the services billed herein available to any and all authorized Department representatives and Federal authorities. * Failure to maintain adequate records shall establish a presumption in favor of the State for any funds paid by the State for which adequate documentation is not available to support disbursement. * In order to be considered exempt from DCFS licensing, I can care for no more than three children during any given day, including my own children, unless all children are from the same household. * If not licensed by DCFS, copies of my Social Security Card and current driver's license, State ID card, or military ID are included. In order to be current, the driver's license or ID must list my current address. * I declare under penalty of perjury that I have read all statements on this form and the information I give is true, correct and complete to the best of my knowledge. I understand that giving false information or failing to provide correct information can also result in an overpayment which I will have to pay back and could result in my prosecution for fraud. * That the rates charged to the State of Illinois do not exceed the maximum allowed by the State and do not exceed those charged to the general public for similar services. This includes discounts such as multiple child discounts, staff discounts, full-week discounts, per-pay discounts, and sliding fee scales. * I certify that the hours of child care do not include hours the child is in school. * That deliberately providing an incorrect/fictitious Social Security number in order to defraud the State of Illinois will cause me to be prosecuted to the fullest extent of the law. * My signature is my consent and authorization for information to be released to the Illinois Department of Human Services or its agents that may establish my eligibility or my continued eligibility for the Child Care Program. By signing and dating this document I certify that I have read and understand all the statements listed above. I certify that the statements as they are listed are true and that the information provided on this application is true, correct and complete	Text
SECTION 7 - CHILD CARE PROVIDER CERTIFICATION	Text
Child Care Provider Signature	Text	Enter the signature of the child care provider.
Signature Date	Date	Enter the date this document is signed.
Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
Parent/Guardian Signature	Text	Enter the signature of the parent or guardian.
After reading each of the following statements, I certify that: * I understand that I am responsible for paying a share of my child care costs (parent co-payment) to my child care provider and that failure to do so may result in the loss of my child care provider. * I understand that my eligibility will be redetermined every six (6) months or as needed. * The child(ren) is/are current on all immunizations and verification is on file with the child care provider. * A review of each facility/home has been completed and I agree that it is a safe environment. * I have given written notification to each child care provider if I want anyone other than myself to pick up the child(ren). * An emergency phone number and written consent for medical care and for dispensing prescription medication has been given to each child care provider. * The name of the family physician is on file with each child care provider. * I am responsible for the selection of the child care providers for my child(ren). * I will report any change in child care arrangements, employment or family size, within 10 days. Failure to report changes in a timely manner may result in an overpayment which I will have to pay back and/or loss of child care benefits. * I understand that I must be working or attending and IDHS approved education, training, or other work related activity in order to be eligible to receive child care benefits. * I understand the information provided will be checked using State and other databases, and if inconsistencies are discovered, the processing of my application may be delayed or denied. * I understand that deliberately providing an incorrect/fictitious Social Security number or withholding the Social Security number information in order to defraud the State of Illinois will cause me to be prosecuted to the fullest extent of the Law. * The information provided will be disclosed only for administrative purposes and that I may be required to verify the information that I have provided. * I understand that I have the right to appeal and to have a fair hearing of a grievance. * I declare under penalty of perjury that I have read all statements on this form and the information I give is true, correct and complete to the best of my knowledge. I understand that giving false information or failing to provide correct information can also result in an overpayment which I will have to pay back and could result in my prosecution for fraud. My signature is my consent and authorization for information to be released to the Illinois Department of Human Services or its agents that may establish my eligibility, or my continued eligibility for the child care	Text
SECTION 8 - PARENT/GUARDIAN CERTIFICATION	Text
Parent/Guardian Signature Date	Date	Enter the date the parent or guardian signed the form.
Other Parent/Guardian Signature Date	Date	Enter the date the other parent or guardian signed the form, if applicable.
Other Parent/Guardian Signature	Text	Enter the signature of the other parent or guardian, if applicable.
Parent/Guardian Name	Text	Enter the full name of the parent or legal guardian applying for child care services.
More Than One Child Care Provider (Yes/No)
More Than One Child Care Provider (Yes/No)	Text	Enter either 'Yes' or 'No' to indicate whether you have more than one child care provider for this application.
More Than One Child Care Provider - Yes	Checkbox	Check this box if you have more than one child care provider for this application (you must complete a separate child care arrangement Section 4 for each provider).
More Than One Child Care Provider - No	Checkbox	Check this box if you do not have more than one child care provider for this application (you have only one provider listed).
Notes
FREQUENTLY ASKED QUESTIONS ABOUT CHILD CARE ASSISTANCE CHILD CARE ASSISTANCE PROGRAM OVERVIEW 1) Who is eligible for child care assistance from the state? * Income eligible working families; * TANF clients in education, training, or other work-related activities approved by their caseworkers; * Teen parents (under age 20) in elementary or high school, or a GED program; * Income eligible families who are in school or training and are not receiving TANF cash assistance. * Occupational/vocational training, GED, ABE, ESL, and other below post-secondary education programs do not have a work requirement for the first 24 months. High school does not have a work requirement. 2) Is there a waiting list for child care assistance? No. Anyone who meets the eligibility requirements may receive a child care assistance. 3) How long can I continue to receive child care assistance? There is no time limit. As long as you are income eligible and need child care to work or participate in an approved activity, you remain eligible. Your Approval Letter will list the first and last months that you are eligible for assistance. Usually, you will be approved for 3 or 6 months at a time. Before your approval period ends, you will have to renew your child care case in order to continue receiving assistance. You will do this by filling out a “redetermination” form. This form will be automatically mailed to you in the month before your approval period ends. For example, if you are approved through April, you should receive your redetermination form in March. If you don't return your redetermination form and all required documents -OR- if you no longer meet the eligibility guidelines of the program, your case will be canceled	Text
Other Child Care Providers Not on This Application (List)
Other Child Care Providers — List	Text	Enter the names of all other child care providers (for example Head Start, Pre-K, or outside child care) not listed on this application; include each provider’s program type, name, city/location and registration or case number if known, separated by line or comma. Fill only if 'Other children attend Head Start/Pre-K/Child Care (Yes)' is 'Yes'.
Other Children in Head Start/Pre-K/Other Provider (Yes/No)
Do any of your other children attend Head Start, Pre-K or Child Care at a provider not on this application? Yes	Text
Other children attend Head Start/Pre-K/Child Care (Yes)	Checkbox	Check this box if one or more of your other children attend Head Start, Pre-K, or child care at a provider who is NOT listed on this application.
Other children attend Head Start/Pre-K/Child Care (No)	Checkbox	Check this box if none of your other children attend Head Start, Pre-K, or child care at a provider who is not listed on this application.
Other Family Members Table Header
Other Family Member's Last Name	Text	Provide the last name of the other family member.
Other Family Member's Date of Birth	Date	Provide the date of birth for the other family member.
Other Family Member's Relationship to Applicant	Text	Specify the relationship of this family member to the applicant.
Other Family Member's Social Security Number (Optional)	Text	Enter the social security number for the other family member, if available.
Parent/Guardian Contact Information
Home Telephone Number	Text	Enter your home telephone number, including area code and extension if applicable.
Alternate Contact Telephone Number	Text	Provide another phone number where you can be reached, including area code and any extension.
E-mail Address	Text	Enter your primary email address for contact.
Best Time to Call	Text	Indicate the best time(s) to call you (for example 'Mornings', 'After 5pm', or a specific time range).
Mobile Telephone Number	Text	Enter your mobile or cell phone number, including area code.
Parent/Guardian Date of Birth and Sex
Parent/Guardian Date of Birth	Date	Enter the parent or guardian's date of birth.
Sex - Male	Text	Enter 'Male' to indicate the parent/guardian's sex is male.
Male	Checkbox	Check this box if the parent/guardian's sex is Male.
Sex - Female	Text	Enter 'Female' to indicate the parent/guardian's sex is female.
Female	Checkbox	Check this box if the parent/guardian's sex is Female.
Parent/Guardian Home Address
Home Street Address (Parent/Guardian)	Text	Enter the parent/guardian’s full street address including house number and street name (do not put apartment/unit here if it has its own box).
Apt/Unit # (Parent/Guardian)	Text	Enter the apartment, unit, or suite number for the parent/guardian’s home address, or leave blank if none.
City (Parent/Guardian)	Text	Enter the city for the parent/guardian’s home address.
State (Parent/Guardian)	Text	Enter the state for the parent/guardian’s home address, preferably using the two-letter state abbreviation.
ZIP Code (Parent/Guardian)	Text	Enter the ZIP code for the parent/guardian’s home address (5-digit ZIP or ZIP+4).
Parent/Guardian Identifiers (SSN/Case/County)
Social Security Number (Optional)	Text	Enter the parent/guardian's Social Security Number if you choose to provide it; leave blank if you do not wish to provide this optional information.
TANF/Food Stamps (SNAP)/Medical Assistance Case Number	Text	Enter the TANF, SNAP (food stamps), or medical assistance case number for the parent/guardian if one applies (leave blank if not applicable).
County	Text	Enter the name of the county where the parent/guardian resides.
Parent/Guardian Language Preference
Language Preference (primary)	Text	Enter the parent/guardian's primary spoken language (for example: English, Spanish, Polish, Chinese) as the language preference.
English	Checkbox	Check this box if the parent/guardian's preferred language is English.
Spanish	Checkbox	Check this box if the parent/guardian's preferred language is Spanish.
Polish	Checkbox	Check this box if the parent/guardian's preferred language is Polish.
Chinese	Checkbox	Check this box if the parent/guardian's preferred language is Chinese.
Language Preference – Other (specify)	Text	If the parent's language is not listed, type the name of the other language the parent/guardian prefers to use. Fill only if 'English', 'Spanish', 'Polish', 'Chinese' is 'No' (all).
Parent/Guardian Mailing Address (If Different)
Mailing Address (if different) - Street	Text	Enter the parent/guardian's mailing street address here, including apartment or unit number if applicable.
Mailing Address - ZIP Code	Text	Enter the ZIP code for the parent/guardian's mailing address (5-digit ZIP or ZIP+4).
Mailing Address - State	Text	Enter the state for the parent/guardian's mailing address (use the two-letter abbreviation or full state name).
Mailing Address - City	Text	Enter the city for the parent/guardian's mailing address.
Parent/Guardian Name
KEEP FOR YOUR RECORDS The State of Illinois helps income eligible families pay for their child care services while they work or go to school, training and other work-related activities. To apply please read the following pages carefully and then submit your completed application to your local Child Care Resource and Referral (CCR&R) or child care center/home if they have a contract with IDHS to provide child care assistance. If you have any questions about your eligibility or if you need help completing this form, call your local CCR&R. To find your local CCR&R go to http://www.inccra.org/find-your-local-ccrr-other or call 1-877-202-4453 (toll-free). Please be sure that all the information is complete before sending in your application: * The application is filled out clearly in blue or black ink. * All questions on the application are completed. If the section or question does not apply, please write "n/a" in the box to show the question was not missed. * Complete this form based on your current information. Inform the CCR&R or Site provider if any information changes in the future. * The parent/guardian's name is listed at the top of each page of the application. * The application is signed by the client (parent) and child care provider (pages 13 & 14). * Social security numbers are listed clearly or "n/a" is listed in the box. Social security numbers are not required for parents or children but they are used to gather information to help determine your eligibility for child care assistance. Providers MUST list their valid tax identification number (SSN, FEIN, Gov't unit code) or IDHS Provider Registration Number. All information is confidential and will not be shared with anyone. * All Family Information is complete in section 3 of the application including information about your children's immigration status. Children can get assistance regardless of their immigration status, but IDHS is required to ask for this information. This information will not be shared with anyone. Your child's alien registration number must be listed if they have one. * All persons other than the applicant and the second parent living in the household are listed in section 3 (page 6). * If working, at least one of the following is attached to verify your employment and the employment of everyone listed in your family size that is 19 years of age or older: * Copies of your last two (2) paycheck stubs, or (if you have not been working long enough to get two paychecks). * A letter from your employer or an employment verification form listing the following: * The date you started working. * The amount of money you are paid. * Your typical work schedule, including the total number of hours you work per week. * Your employer's address and phone number. * Your employer's signature, or * Verification of your self-employment. This can include: * A copy of your most recent Federal Income tax return (IRS 1040) and all schedules and attachments. * A copy of your quarterly estimated taxes. * A listing of all business income and expenses for the last 30 days. This can be reported on your own form or on a Self-Employment form which can be downloaded at: http://www.dhs.state.il.us/OneNet Library/27897/documents/Forms/IL444-2790.pdf or requested from your local CCR&R. When reporting income and expenses, all receipts, invoices, or other documentation must be attached to verify all information. * If in school, ALL of the following are attached: * Copies of your official school schedule. * Copies of your most recent report card showing your cumulative grade point average (GPA). * You have made a copy of your application for your records. You understand if you send original check stubs or other documents that they will not be returned. * All jobs and income information for BOTH parents have been reported on pages 3 and 5 and documentation is attached. * You understand that if any questions are left blank or if any attachments are missing, your application will be returned to you as incomplete. This may cause a delay in approval for Child Care Assistance Program payments. * You also understand that all of the information you submit will be verified using State and/or local databases and the internet. If any inconsistencies are discovered, your application may be delayed or your participation in the Child Care Assistance Program may be denied	Text
Parent/Guardian Name	Text	Enter the full legal name of the parent or guardian completing this application (first, middle if applicable, and last name).
Parent/Guardian First Name	Text	Enter the parent or guardian's first (given) name as it appears on official documents.
Parent/Guardian Middle Initial	Text	Enter the parent or guardian's middle initial (single letter) or leave blank if none.
Parent/Guardian Last Name	Text	Enter the parent or guardian's last (family) name or surname as it appears on official documents.
Parent/Guardian Name	Text
Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
Parent/Guardian Name	Text	Provide the full name of the parent or guardian for the child care application.
21) How can my child care provider expect to be paid? IDHS is offering for family home child care providers to receive their payments through the Illinois Debit MasterCard. The Debit Card presents the opportunity for home child care providers to receive their payments in a quicker, less expensive manner than a paper check. The provider will receive payment for all children they are providing care for on one card. No more worrying about lost or stolen checks! Each month the provider will receive a statement identifying each case for which they are receiving payment. For more information regarding the Illinois Debit MasterCard, go to the following website: http://www.dhs.state.il.us/page.aspx?item=45466 or contact your CCR&R. Payments can be deposited directly into your provider's bank account. This can be especially helpful if your provider has been having trouble with mail. Call 217-557-0930 to set up direct deposit. For purposes of record keeping, your provider may want to ask the bank what kind of receipt information they can pass on, as the provider will not receive payment information from IDHS or the Comptroller's office when using direct deposit. Effective September 20, 2011, Home Child Care Providers will receive all provider payments on the Illinois Debit Mastercard card unless they choose direct deposit. Paper checks will remain an option if the provider cannot accept an electronic method for receiving funds. The IDHS Child Care Telephone Billing System is an easier and faster way to get paid. Contact your CCR&R for more information. 22) How can I or my child care provider check status of payments? Clients and providers can call the IDHS toll free phone number to find out payment information. If you have a touch-tone phone, you can call 1-800-804-3833 to find out if your payments have been entered by the CCR&R and mailed by the State Comptroller. This toll free number is available 24 hours a day, seven days a week. You can also get payment information by visiting the State Comptroller's web site at: www.comptroller.state.il.us and select "vendor payments." OTHER 23) What should I do if my circumstances change? The parent or provider should call us when any of the following changes occur: * Change Providers * Change address * Stop working or change jobs * Stop receiving TANF * Stop attending school or training * Have medical/maternity leave * Change family size * Have any other changes that may affect your eligibility * Change income Failure to report any changes within 10 days may result in an overpayment which you will have to pay back and/or loss of child care benefits. If you stop working, you may be able to continue to receive a child care subsidy up to 30 days after the loss of your job while you look for work. 24) If I am a client or child care provider and I move, will my mail and checks be forwarded? No, all clients and providers must fill out and submit a client/provider address form within 10 days of relocating. 25) How can I verify employment if I am self employed or cash paid? A copy of the most recent, signed federal income tax return and all applicable schedules and attachments. After April 15th of each year, only the tax return for the previous year is acceptable. If the tax return was submitted electronically, you must provide a copy of the receipt in the absence of a signature. If a tax return is not available, a monthly statement of earnings and expenses must be submitted until an income tax return is submitted. If you are paid in cash, a payment verification letter is required from each individual who pays you in cash for performing a service. You cannot write the letter yourself. It MUST be from the person who pays you. All verifications must include the following information: 1. The name, address, and phone number, of the individual completing the letter; 2. The type of work performed; 3. Who performed the work; 4. The date(s) the work was completed or if the activity is on-going; 5. The rate of pay; and 6. The employee's schedule. If the expenses exceed the gross receipts, the self-employment income will be zero (-0-). Those additional expenses which exceed the gross receipts will not be subtracted from other earned or unearned income in the household. If the number of hours worked cannot be verified, the amount of child care services allowed shall not exceed the documented income divided by the current State minimum hourly wage. Example: A parent reports that she cleans 5 homes per week and only earns $100 per week. To calculate the number of hours/days to approve, divide $100 by $8.25 (State minimum wage effective 7/1/10) = 12.12 hours. Depending on the parent's actual work/transportation schedule, the parent could be approved for either: 1 full and 1 part time day, 2 full and 1 part day, or 3 part days of care	Text
Parent/Guardian Name	Text	Enter the full name of the parent or guardian.
Parent/Guardian Name (Header)
Important Notice: The sooner your application is submitted, the sooner benefits can be determined	Text
Parent/Guardian Name	Text	Enter the full name of the parent or guardian responsible for the child (provide first name, middle initial if any, and last name).
Provider Information
Provider Name	Text	Enter the name of the child care provider.
Provider Registration Number	Text	Enter the registration number for the child care provider.
Return Completed Application To
PLEASE TYPE OR PRINT CLEARLY IN BLUE OR BLACK INK. Please read the attached checklist before completing this form. (Este formulario está disponible en español. For the Spanish version go to http://www.dhs.state.il.us/onenetlibrary/27897/documents/forms/IL444-3455S.pdf)	Text
Return Completed Application To	Text	Enter the name and full mailing address (agency or person, street address, city, state, ZIP and any attention line) where the completed application should be returned.
Second Child Care Schedule
No	CheckBox
Year Round	CheckBox
Is the school at the same location as the provider	Text
Yes	CheckBox
Second Child Schedule Monday From AM	Checkbox	Check this box if the second child's care typically begins on Monday mornings.
Second Child Schedule Monday From PM	Checkbox	Check this box if the second child's care typically begins on Monday afternoons or evenings.
Second Child Schedule Monday To PM	Checkbox	Check this box if the second child's care typically ends on Monday afternoons or evenings.
Second Child Schedule Monday To AM	Checkbox	Check this box if the second child's care typically ends on Monday mornings.
Second Child Tuesday To Time	Time	Enter the time the second child's care ends on Tuesday.
Second Child Tuesday From Time	Time	Enter the time the second child's care begins on Tuesday.
Second Child Wednesday To Time	Time	Enter the time the second child's care ends on Wednesday.
Second Child Wednesday From Time	Time	Enter the time the second child's care begins on Wednesday.
Sample Schedule of Hours in Child Care	Text
Second Child Thursday To Time	Time	Enter the time the second child's care ends on Thursday.
Second Child Thursday From Time	Time	Enter the time the second child's care begins on Thursday.
Second Child Saturday To Time	Time	Enter the time the second child's care ends on Saturday.
Second Child Saturday From Time	Time	Enter the time the second child's care begins on Saturday.
Sample Schedule of Hours in Child Care	Text
Second Child Sunday To Time	Time	Enter the time the second child's care ends on Sunday.
Second Child Sunday From Time	Time	Enter the time the second child's care begins on Sunday.
Second Child Friday To Time	Time	Enter the time the second child's care ends on Friday.
Second Child Friday From Time	Time	Enter the time the second child's care begins on Friday.
Sample Schedule of Hours in Child Care	Text
Second Child Daily Rate	Number	Enter the daily rate for the second child's care.
Second Child Care Time Range
Second Child Age	Text	Provide the age of the second child for whom child care is being arranged.
Second Child Information
Second Child Gender M	Text	Enter 'M' if the second child is male.
Second Child Date of Birth	Date	Enter the date of birth for the second child.
Second Child Last Name	Text	Provide the last name of the second child.
Second Child First Name	Text	Provide the first name of the second child.
Second Child U.S. Citizen Yes	Checkbox	Check this box if the second child is a U.S. citizen.
Second Child U.S. Citizen No	Checkbox	Check this box if the second child is not a U.S. citizen.
Second Child Ward of State Yes	Checkbox	Check this box if the second child is a ward of the state.
Second Child Ward of State No	Checkbox	Check this box if the second child is not a ward of the state.
Second Child Relationship to Client	Text	State the second child's relationship to the client.
Second Child Social Security Number	Text	Provide the social security number for the second child.
Second Child Ethnic Origin	Text	Provide the ethnic origin of the second child.
Second Child Gender F	Text	Enter 'F' if the second child is female.
Second Child Age	Text	Enter the age of the second child.
Second Child's Name	Text	Enter the full name of the second child.
Second Child Relationship to Client	Text	Enter the relationship of the second child to the client.
Second Child Multi-child Discount
Second Child Multi-child Discount Explanation	Text	Enter a detailed explanation of the multi-child or family discount offered for the second child.
Does the provider offer a multi-child/family discount	Text
Second Child Multi-child Discount Yes	Checkbox	Check this box if the provider offers a multi-child/family discount for the second child.
Second Child Multi-child Discount No	Checkbox	Check this box if the provider does not offer a multi-child/family discount for the second child.
Second Child Schedule Variation
Second Child Schedule Variation Yes	Checkbox	Check this box if the child care schedule for the second child varies.
Second Child Schedule Variation No	Checkbox	Check this box if the child care schedule for the second child does not vary.
Second Child Schedule Variation Explanation	Text	Enter the reasons or details explaining why the second child's care schedule varies.
Second Child School Attendance
Second Child School Hours	Number	Please provide the number of hours the second child is in school.
Does the child listed attend school	Text
Second Child School Attendance Yes	Checkbox	Check this box if the second child listed attends school.
Second Child School Attendance No	Checkbox	Check this box if the second child listed does not attend school.
Second Child School Attendance Year Round	Checkbox	Check this box if the second child listed attends school year-round.
Second Child School Location
Second Child School Location Yes	Checkbox	Check this box if the second child's school is at the same location as the child care provider.
Second Child School Same Location Yes	Text	Indicate if the second child's school is at the same location as the provider.
Second Child School Location No	Checkbox	Check this box if the second child's school is not at the same location as the child care provider.
Second Other Family Member
Second Other Family Member First Name	Text	Enter the first name of the second other family member.
Second Other Family Member Last Name	Text	Enter the last name of the second other family member.
Second Other Family Member Social Security Number	Text	Enter the social security number of the second other family member.
Second Other Family Member Relationship to Applicant	Text	Enter the relationship of the second other family member to the applicant.
Second Other Family Member Date of Birth	Date	Enter the date of birth for the second other family member.
Section I - Parent/Guardian Information (Header)
Parent/Guardian Name (Header)	Text	Enter the full name of the parent or guardian completing this application (first and last name as a single string).
Seventh Other Family Member
Seventh Other Family Member Social Security Number	Text	Enter the social security number of the seventh other family member.
Seventh Other Family Member Relationship to Applicant	Text	Enter the relationship of the seventh other family member to the applicant.
Seventh Other Family Member Date of Birth	Date	Enter the date of birth of the seventh other family member.
Seventh Other Family Member Last Name	Text	Enter the last name of the seventh other family member.
Seventh Other Family Member First Name	Text	Enter the first name of the seventh other family member.
Sixth Other Family Member
Sixth Other Family Member Last Name	Text	Enter the last name of the sixth other family member.
Sixth Other Family Member Date of Birth	Date	Enter the date of birth for the sixth other family member.
Sixth Other Family Member First Name	Text	Enter the first name of the sixth other family member.
Sixth Other Family Member Relationship to Applicant	Text	Enter the relationship of the sixth other family member to the applicant.
Sixth Other Family Member Social Security Number	Text	Enter the Social Security Number for the sixth other family member, if applicable.
SSN Confidentiality Acknowledgment Initials
SSN Confidentiality Initials (1)	Text	Enter your initials to acknowledge you have read and understand the Social Security Number confidentiality statement shown on this form.
Third Child Information
Third Child's Gender	Text	Indicate the gender (M/F) of the third child.
Third Child's Date of Birth	Date	Provide the date of birth for the third child.
Third Child's Last Name	Text	Enter the last name of the third child.
Third Child's First Name	Text	Enter the first name of the third child.
Third Child U.S. Citizen Yes	Checkbox	Check this box if the third child is a U.S. citizen.
Third Child U.S. Citizen No	Checkbox	Check this box if the third child is not a U.S. citizen.
Third Child Ward of State Yes	Checkbox	Check this box if the third child is a ward of the state.
Third Child Ward of State No	Checkbox	Check this box if the third child is not a ward of the state.
Third Child's Relationship to Client	Text	Provide the relationship of the third child to the primary client.
Third Child's Social Security Number	Text	Enter the Social Security Number of the third child.
Third Child's Ethnic Origin Part 2	Text	Enter the second part of the ethnic origin for the third child.
Third Child's Ethnic Origin Part 1	Text	Enter the first part of the ethnic origin for the third child.
Third Other Family Member
Third Other Family Member Last Name	Text	Enter the last name of the third other family member.
Third Other Family Member First Name	Text	Enter the first name of the third other family member.
Third Other Family Member Social Security Number	Text	Enter the social security number of the third other family member.
Third Other Family Member Relationship to Applicant	Text	Enter the relationship of the third other family member to the applicant.
Third Other Family Member Date of Birth	Date	Enter the date of birth of the third other family member.
Total Pages
4) If I receive child care assistance from the State will I still have to pay something? The State requires all parents to pay a monthly "co-payment" directly to their provider. The amount of your monthly co-payment is determined by IDHS and the amount may vary from parent to parent. Monthly co-payments are based on gross monthly income, family size, and number of children in child care. The amount of your monthly co-payment will be listed on your Approval Letter. The State will deduct the parent co-payment from the total charges up to the maximum child care rate. If the co-payment is more than the total charges, the parent pays the lesser amount to the provider and no payment is made by the State. 5) How can I find a child care provider? You may call a parent counselor at your local Child Care Resource & Referral Agency (CCR&R) at 1-877-202-4453 (toll-free) to get help finding child care for your child. You must have a child care provider before you submit your application. 6) Will my information be verified? Yes. Information submitted by the parent/guardian on the application and supporting documentation is verified through various agencies' databases and internet websites. Databases used include, but are not limited to: TANF, Food Stamps, Medical, employment Security, Department of Labor, Social Security Administration, Child Support Enforcement, and Chicago Public Schools. Information from these databases and websites will be taken into consideration when determining eligibility. ELIGIBILITY CRITERIA 7) What does “income eligible” mean? A family is considered income eligible when the combined gross monthly income of all family members is at or below the amounts listed below for the corresponding family size. In two-parent families, both incomes must be combined to determine eligibility. Two-parent families include those with 2 or more adults living in the home, such as the applicant and his or her spouse or parents of a common child in the home. 8) Must I be the child's parent to qualify for the program? No. A child's legal guardian or other relatives caring for the child are also eligible and should fill out an application form. Foster parents can receive child care assistance from the Department of Children and Family Services. 9) How old can the child be? All children under age 13 are eligible. Children 13 or older are eligible if they are under court supervision or have written documentation from a medical provider stating that they are physically or mentally incapable of caring for themselves. 10) Can I receive child care assistance for the time I travel to or from work or school/training? Yes. You can receive child care assistance for reasonable time you spend traveling to and from your child care provider to your job or school /training, as well as for the time you are working or attending school/training	Text

State of Illinois Department of Human Services (IDHS) – Bureau of Child Care and Development Child Care Application (Form IL444-3455) Instructions