APPLYING FOR CHILD CARE SUBSIDY AND SERVICES
Information You Need to Know
Anyone may apply for child care services. You must apply in the city or county in which you live. You do not need to have lived in the city or county for any specified length of time. The child(ren) for whom the child care service application is submitted must be a citizen of the United States or have legal alien status. Proof of the child(ren)’s citizenship or legal alien status must be provided.
To find out if you are eligible to receive child care services, you must complete and return the attached application.
Applicant’s Rights
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex, religion or political beliefs. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Additionally, program information may be made available in languages other than English.
To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS) write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).
You have the right to view the information in your child care case record. The local department may not release information about you without your written consent, with the exception of purposes directly connected with the administration of social service programs, or by court order.
You have the right to visit your child any time the child is in the provider’s care. You also have the right to make complaints or discuss areas of concern regarding your provider’s care by calling 1-800-543-7545 or on-line at childcareva.com
KEEP THIS PAGE FOR YOUR RECORDS
Instructions for Completing the Application
If you need help completing this application, a friend, relative, or your child care case manager can help you. If you are completing this application for someone else, answer each question as if you were that person. If you need to change an answer or make a correction, write the correct information nearby and insert your initials and date next to the change. If there are more people living in your household and you need more space to list everyone, tell the local department you require extra pages. If you have a disability or have difficulty with English, you may receive help to ensure you get the services you are eligible to receive.
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Do not write in shaded areas. These areas are for agency use only.
- Complete SECTION 1: APPLICANT INFORMATION.
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Complete SECTION 2: HOUSEHOLD MEMBERS.
Include everyone living in the household. -
Complete SECTION 3: CHILDREN WHO NEED SERVICES.
Include each child for whom you are applying for child care assistance. You may leave questions about citizenship and immigration blank for anyone for whom you are NOT requesting assistance. -
Complete SECTION 4: WORK/SCHOOL/TRAINING.
Include every adult member living in the household. -
Complete SECTION 5: INCOME and RESOURCES.
Include everyone living in the household.
- Read SECTION 6: RESPONSIBILITIES, CHANGE REPORTING, AND PENALTIES.
- Read and complete SECTION 7: CONSENT TO EXCHANGE INFORMATION.
- Read and complete SECTION 8. Be sure to sign and date the application.
Complete and Accurate Information
Filing the Application
KEEP THIS PAGE FOR YOUR RECORDS
LDSS USE ONLY | |||
Date Application Received: | Date of Interview: | ||
In Office | Telephone | ||
LDSS: | FIPS: | ||
Case#: | Program Category: |
CHILD CARE SUBSIDY SERVICE APPLICATION AND REDETERMINATION FORM
1. Applicant Information – tell us about you. |
Your Name: Last |
First |
Middle Initial |
Maiden or Other |
Social Security Number (optional): |
Date of Birth: |
Gender: |
Relationship to the child(ren): |
Physical address: |
City: |
State: |
Zip: |
Mailing address: (if different than physical address) |
City: |
State: |
Zip: |
Are you over the age of 18, or a legally emancipated minor? Yes No | |||
Has the family been homeless for one or more days during the month
of thisapplication? Yes
No
Is the family currently residing in any type of shelter? Yes No NOTE: Homeless is defined as individuals who lack a fixed, regular, and adequate nighttime residence. |
|||
Email address: |
Cell phone number:
Service provider: |
Home number: |
Work number: |
How would you like for us to contact you? Telephone U.S. Mail Email | |||
If you would like to receive either a text message or an email
notifying you that some correspondence about your benefits can be
accessed electronically through CommonHelp
(www.CommonHelp.xxxxxxx.gov), select one of the choices below. List
either a cell telephone number or an email address. Once you choose
a preferred electronic method of correspondence, it will be used for
all programs on the case for which you have applied.
If you do not choose to be notified through a text or an email,
you will receive all written correspondence through the U.S.
Mail.
If you would you like to receive electronic correspondence/notices, please select your preferred method. Email Text |
Family Composition (Select One) |
Your Marital Status
(Select One)
|
Your Educational Level
(Select One)
|
||
Single Parent Family
Two Parent Family
Single Parent Guardian
Two Parent Guardian
|
Single
Married
Separated
Divorced
Widowed
|
Less than High School Graduate
High School Graduate
GED
Post Graduate (College)
|
||
Your Race | Your Ethnicity |
Language
What is the primary language spoken in the home?
|
||
White
African-American
Asian
American Indian/Alaskan Native
Native Hawaiian or Pacific Islander
|
Hispanic/Latino Yes No |
English
Spanish
Cambodian
Vietnamese
Farsi
Haitian-Creole
|
Laotian
Chinese
Korean
Somali
Kurdish
Arabic
|
French
German
Japanese
Other
|
2. Tell us who lives in your home.List your name on the first line. |
Yes No | |||||||
Yes No | |||||||
Yes No | |||||||
Yes No | |||||||
Yes No | |||||||
Yes No | |||||||
Yes No | |||||||
Yes No | |||||||
Yes No |
* Race: White, African-American, Asian, American Indian/Alaskan Native, Native Hawaiian or Pacific Islander |
Have you or anyone in your household ever been disqualified from receiving Child Care assistance? Yes No |
Have you or anyone in your household ever been disqualified from
receiving Child Care assistance? Yes
No
If YES, please explain: |
Have you or anyone in your household received within the past twelve
months any benefits listed below from either this local department
or another locality? Yes No Select which benefits were received: Energy Assistance Child Care Medical Assistance SNAP TANF |
3. Tell us about the children who need child care services. Add additional pages if necessary. |
Female Male | Female Male | Female Male | Female Male | |
White African-American Asian American Indian/Alaskan Native Hawaiian or Pacific Islander |
White African-American Asian American Indian/Alaskan Native Hawaiian or Pacific Islander |
White African-American Asian American Indian/Alaskan Native Hawaiian or Pacific Islander |
White African-American Asian American Indian/Alaskan Native Hawaiian or Pacific Islander |
|
Yes No |
Yes No |
Yes No |
Yes No |
Is the child a U.S. citizen? | Yes No | Yes No | Yes No | Yes No |
If the child is not aU.S. citizen, are they a legalalien? | Yes No | Yes No | Yes No | Yes No |
Does the child have a disability or special need? | Yes No | Yes No | Yes No | Yes No |
Are the child’s immunizations up- to- date? | Yes No | Yes No | Yes No | Yes No |
Is the child currentlyenrolled in a Head Startprogram? | Yes No | Yes No | Yes No | Yes No |
Does the child currently attend school? | Yes No | Yes No | Yes No | Yes No |
Is child care needed all year? | Yes No | Yes No | Yes No | Yes No |
Is child care needed for the school year only? | Yes No | Yes No | Yes No | Yes No |
Is child care needed for school breaks and summerbreaks only? | Yes No | Yes No | Yes No | Yes No |
Note: Your child’s social security number is optional and may be used to verify case information and assist the local department in processing your application. Failure to provide their social security number will not affect your child’s eligibility for child care services. Checking No under immunizations up-to -date does not automatically disqualify your child. You must select a race and ethnicity for each child.
4. Tell us where you work or attend school or training. Add additional pages if necessary. |
Parent A – Work/School/Training Information | Parent B – (spouse, co-habitant, or child’s other parent, if in same household) Work/School/Training Information |
Name of Parent/Guardian: | Name of Parent/Guardian: |
Employment/School/Training Status: (Check all that apply) Employed Employed/Attending School/Training Attending School/Training Disabled |
Employment/School/Training Status: (Check all that
apply) Employed Employed/Attending School/Training Attending School/Training Disabled |
Employer |
School/Training Program Attending: |
Employer |
School/Training Program Attending: |
Employer Address: (Including city, state, zip) |
School/Training Address: |
Employer Address: (Including city, state, zip) |
School/Training Address: |
Employer’s Phone Number: |
School/Training Phone Number: |
Employer’s Phone Number: |
School/Training Phone Number: |
Employment Start Date: |
School/Training Start Date: |
Employment Start Date: |
School/Training Start Date: |
How many hours do you work each week? |
How many hours do you attend school/training each week? |
How many hours do you work each week? |
How many hours do you attend school/training each week? |
Work Schedule (example 8-5): | Work Schedule (example 8-5): |
Mon. | Tue. | Wed. | Thur. | Fri. | Sat. | Sun. | Mon. | Tue. | Wed. | Thur. | Fri. | Sat. | Sun. |
Mon. | Tue. | Wed. | Thur. | Fri. | Sat. | Sun. | Mon. | Tue. | Wed. | Thur. | Fri. | Sat. | Sun. |
Is this parent currently serving in the military?
Employed Yes, active duty US military Yes, National Guard/Military Reserve |
Is this parent currently serving in the military?
Employed Yes, active duty US military Yes, National Guard/Military Reserve |
5. Tell us about your family income and resources. |
Does the family have assets/resourcesthat exceed
$1,000,000?
Yes No
May include, but not limited to: cash on hand, checking or savings account balance, stocks or bonds, trust funds, pension plans, or retirement accounts. Enter the amount of all income received by you or any other household member. (You must check Yes or No for each source below currently received or received within the past 12 months) |
Source |
Check Yes or No for each |
*Pay Frequency |
Gross Amount Per Pay |
Source |
Check Yes or No for each |
*Pay Frequency | Gross Amount Per Pay |
Employment (You) | Yes No | Alimony | Yes No | ||||
Employment (Other household member) | Yes No | Child Support | Yes No | ||||
Self-employed | Yes No | Contract Income | Yes No | ||||
Housing Voucher or Cash Assistance | Yes No | Unemployment | Yes No | ||||
TANF | Yes No | Disability Income | Yes No | ||||
Social Security | Yes No | Worker’s Compensation | Yes No | ||||
SSI or Other Federal Cash Benefits | Yes No | Farm Income | Yes No | ||||
Pensions | Yes No | Rental Income |
Yes No |
||||
Other (specify) | Yes No | Other (specify) | Yes No |
* Pay frequency: Weekly, Bi-weekly (every two weeks), Semi-monthly (twice a month), or Monthly. |
Deductions and/or Payments Check |
Check
Yes or No for each
|
Frequency | Gross Amount |
Does anyone pay child support to someone who is not in the household? | Yes No | ||
Does anyone receive a basic allowance for housing if you are military personnel? | Yes No | ||
Does anyone receive a clothing maintenance allowance for military? | Yes No | ||
Is your paycheck being garnished? | Yes No |
6. Responsibilities, Change Reporting, and PenaltiesRead this section carefully before signing this application. |
- Your gross (before taxes) monthly family income amount exceeds the eligibility limit for your family size. See the Notice of Action given to you by the local department of social services for the amount.
- A change in household members.
- A change of address.
- A change of provider.
- A change in your education/training activity (including class days/hours and curriculum).
- A change in the number of hours children need child care.
- A change in employment (including schedule, employer and/or income).
- Any other reduction in household income.
7. Consent to Exchange Information |
If you do not consent to the sharing of your information for the above-stated purposes, your information will remain only within VDSS and will not be shared with any other state agency. Choosing not to share your User Profile will not affect your eligibility for assistance.
Including your Social Security Number (SSN) or the SSN of any dependent in your User Profile is your choice. Your SSN is kept confidential and will not be shared without your expressed and informed consent.
You can withdraw this authorization at any time by notifying your local department of social services.
Your permission to share your User Profile will remain active for one (1) year from the date you approve, unless you change your decision to share sooner. Your agreement for any minor children who turns 18 will be stopped on the date of the child’s 18th birthday
You will be asked to share your information every time you make a change to the information that is used in your User Profile.
8. By signing this application below, I agree that: |
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I have read the information at the beginning of this application and
the Responsibilities, Change Reporting, and Penalties section of
this application.
-
I understand that if I refuse to cooperate with any review of my
eligibility, my child care services may be denied until I
cooperate.
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I authorize the release to the local department of social services
all information necessary to determine and review my eligibility for
child care services. I authorize the release of employment,
education, medical, or child care information obtained from any
source to the state or local department that may review this
application for child care assistance. This authorization is valid
for one year from the date of my signature below. I understand this
time limit does not apply as long as my child care services case is
open or to investigations regarding possible fraud.
-
I understand that it will be necessary to provide certain
information to my child care provider and authorize the release of
such information
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I understand that receipt of Fee Program child care assistance is
limited to 72 months.
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I understand that the xxxxxxxxx Department of Social Services (VDSS)
has limited funding available for the purchase of Child Care Subsidy
Services. The funding for Child Care Subsidy Services changes from
year to year. I further understand that the availability of funding
for child care services cannot be guaranteed. I understand that, if
this funding ends or runs out, I will receive at least 10 days
written advance notice of this action, and that my name may be
placed on the local department’s waiting list at my request
-
I understand that to qualify for these funds I must have a current
need for child care services, I must be working or participating in
an approved educational or training program, and my total household
gross monthly income must not exceed the maximum monthly household
income limit determined by VDSS.
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I must provide complete and accurate information needed for
determining initial and on-going eligibility for child care
services. The local department may request such things as pay stubs,
or permission to contact agencies or individuals to obtain proof of
my income. If I intentionally provide incorrect information, I can
be prosecuted for perjury, larceny, or welfare fraud, and may no
longer be eligible for child care assistance. I must repay any money
paid on my behalf to which I was not entitled.
- My rights and responsibilities have been explained, and I have received a written copy of these
Please print your name: |
Signature of applicant or mark: | Date: |
Representative or Witness (if signed by mark): | Date: |
Child Care Worker signature: | Date: |
Name of person completing application: | Date: |
Phone number: | Relationship to applicant: |
Provider Information: |
Name of Child Care Provider(if selected):
Provider Address: Provider Phone Number:
Name of Secondary ECC cardholder (if applicable):
NOTE: The Department of Social Services WILL NOT pay for any child care provided prior to your child care provider receiving written authorization from the Child Care Subsidy Program
ECC Card: |
Yes No Not Applicable
CHECKLIST: |
To process your application, the local department of social services will need verification of where your family lives and information about your family’s work and/or school schedules
If you are not sure of what documentation to send or need assistance in completing this application, please call your local department of social services.
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