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CHILD CARE ASSISTANCE APPLICATION
First Name (Parent or Guardian) Middle Last Name
Mailing Address City State Zip Code County
Address where you live (if different from mailing) Home Telephone Number Work Telephone Number
---- ----

 

Are the children for whom you are requesting assistance ?


Alien in Satisfactory Immigration Status ? Please submit copies of immigration documents for each child

HOUSEHOLD

 

List everyone who lives in your home, including roomers, boarders, friends and relatives.

 

Acceptable codes under "Race" category are listed below (if you are of mixed race, please check all that apply):

Marital Status:

   

 

If you are of mixed race, please indicate all that apply.

 

Last Name

First Name

Initial

Race (optional)

Sex

Date of Birth

Social Security

Number (optional)

Relationship
Are you Hispanic or Latino ?
Yes    No 		// -- --
     

Check all that apply:

 

 

 

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ----
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ----
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		 // ----
     

Check all that apply:

 

 

   

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		 //  ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		//  ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		//  ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		//  ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		//  ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ---- 
     

Check all that apply:

 

 

  

 

Caucasian
Are you Hispanic or Latino ?
Yes    No 		// ---- 
     

Check all that apply:

 

 

  

 

Caucasian

 

EDUCATION or TRAINING

 

Do you need help paying for child care in order to go to school?     

You must include an official school schedule for each adult family member attending school.

Student’s Name

Place of Training

Credit

Hours

Starting

Date

Ending

Date

Contact Person

Phone

Number
 //  //  ----
 //  //  ----






EMPLOYMENT INCOME

Do you need help paying for child care in order to go to work?     

 
You must attach proof of income:
  The two most recent pay stubs for each adult working in the home:
  A wage verification form if you have a new job and have not yet received two pay stubs:
  If you are self-employed, a complete copy of your most recent income tax return, including all schedules.
Please fill out the following information for each job.  If you have more than three employers, please attach a separate sheet of paper
listing the same information.
Employment #1
Place of Work Supervisor's Name Phone ----
What days of the week do you work ? Mon Tues Wed Thurs Fri Sat Sun
What times do you work ? Total weekly hours worked ?








Hourly wage or salary: $ How often are you paid? Weekly Every two weeks Twice a month Monthly


Employment #2
Place of Work Supervisor's Name   Phone ----
What days of the week do you work ? Mon Tues Wed Thurs Fri Sat Sun
What times do you work ? Total weekly hours worked ?










Hourly wage or salary: $ How often are you paid? Weekly Every two weeks Twice a month Monthly


Employment #3
Place of Work Supervisor's Name   Phone ----
What days of the week do you work ? Mon Tues Wed Thurs Fri Sat Sun
What times do you work ? Total weekly hours worked ?

 

 

 

 

 

 

 

 

 

 

 

 

Hourly wage or salary: $ How often are you paid? Weekly Every two weeks Twice a month Monthly



Do you receive child support payments ? Yes Monthly Amount $ No
Do you receive food stamps ? Yes No
Do you receive Federal rental assistance or live in subsidized housing ? Yes No
List any other sources of income you have, including work-study, interest, pensions, retirement, TANF, Social Security, Veteran's Benefits, periodic/lease income, boarder/roomer rent, workers compensation or unemployment.
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
 Do you make court ordered child support payments?

Yes

To Whom Paid?

Amount  paid per month?

 No 


 
If yes, is the payment made through the SD Division of Child Support Enforcement?
Yes No If no, provide proof of payment (a cancelled check or a receipt from the clerk of courts)

 

CHILD CARE NEED

 
Fill out the following information for each child in child care.  If you need more room, please attach a separate piece of paper listing the same information for each additional child.
Child's Name: Is this child in school?
Yes No


If yes, what hours? (example 8:00-3:15): What days? (check all that apply) Mon Tue Wed Thurs Fri
Is the child in a pre-school program run through the school district or a Head Start program?
Yes No
If yes, please list the name of the program: Contact Person
 
Child's Name: Is this child in school?
Yes No



If yes, what hours? (example 8:00-3:15): What days? (check all that apply) Mon Tue Wed Thurs Fri
Is the child in a pre-school program run through the school district or a Head Start program?
Yes No
If yes, please list the name of the program: Contact Person

Child's Name: Is this child in school?
Yes No


If yes, what hours? (example 8:00-3:15): What days? (check all that apply) Mon Tue Wed Thurs Fri
Is the child in a pre-school program run through the school district or a Head Start program?
Yes No
If yes, please list the name of the program: Contact Person

Child's Name: Is this child in school?
Yes No

 
If yes, what hours? (example 8:00-3:15): What days? (check all that apply) Mon Tue Wed Thurs Fri
Is the child in a pre-school program run through the school district or a Head Start program?
Yes No
If yes, please list the name of the program: Contact Person

 

CHILD CARE PROVIDER

 
If you have more than one child care provider, please fill out the information for each of them.  Please click here    for more information about provider types.

Provider #1 Name: Provider Phone: -- --
Provider address: City
Provider ID Number Cost of care per child: $
Type of provider Regulated In-Progress In-Home Informal Care Relative (list relationship to child)
Does this provider care for all your children?
Yes  No
 (if no, list those cared for):
What days and hours does this provider care for your children?
When did the provider begin caring for your children?

Provider #1 Name: Provider Phone: -- --
Provider address: City
Provider ID Number Cost of care per child: $
Type of provider Regulated In-Progress In-Home Informal Care Relative (list relationship to child)
Does this provider care for all your children?
Yes  No
 (if no, list those cared for):
What days and hours does this provider care for your children?
When did the provider begin caring for your children?

 

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