Form DHR-CMA-1973 "Child Care Assistance Application" - Alabama

What Is Form DHR-CMA-1973?

This is a legal form that was released by the Alabama Department of Human Resources - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2002;
  • The latest edition provided by the Alabama Department of Human Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DHR-CMA-1973 by clicking the link below or browse more documents and templates provided by the Alabama Department of Human Resources.

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Download Form DHR-CMA-1973 "Child Care Assistance Application" - Alabama

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CHILD CARE ASSISTANCE APPLICATION
Instructions:
Please read the application carefully. Complete all sections of the application. Answer each question completely and to the best of
your ability. List everyone in your household. Please print clearly.
The child care application asks you to give us the social security number for everyone in your household. Social security numbers
will help us to process your case more quickly. We will only use your social security number in the administration of the Child
Care Subsidy Program to help us verify your income, make changes in your case and help us assemble research data. If you do not
want to give us the social security number for a member of your household your application for child care will not be denied and
services will not be withheld because you do not give us a social security number.
If you should choose not to give the social security number for some members of your household you must still answer questions
about his or her income and answer the other questions on this form.
Take or mail this application to your local Child Care Management Agency.
DHR-CMA-1973 (April 2002)
CHILD CARE ASSISTANCE APPLICATION
Instructions:
Please read the application carefully. Complete all sections of the application. Answer each question completely and to the best of
your ability. List everyone in your household. Please print clearly.
The child care application asks you to give us the social security number for everyone in your household. Social security numbers
will help us to process your case more quickly. We will only use your social security number in the administration of the Child
Care Subsidy Program to help us verify your income, make changes in your case and help us assemble research data. If you do not
want to give us the social security number for a member of your household your application for child care will not be denied and
services will not be withheld because you do not give us a social security number.
If you should choose not to give the social security number for some members of your household you must still answer questions
about his or her income and answer the other questions on this form.
Take or mail this application to your local Child Care Management Agency.
DHR-CMA-1973 (April 2002)
CHILD CARE ASSISTANCE APPLICATION
WAITING LIST
INITIAL APPLICATION
RE-CERTIFICATION
PARENT INFORMATION:
Applicant/Parent Name _________________________________________ SSN (Optional) ________________________ Date of Birth _____________ Race ________ Sex_______
Marital Status __________ Spouse Name ____________________________ Spouse SSN (Optional) _____________________ Date of Birth _____________ Race _______ Sex ____
Residential Address _____________________________________________City ________________________ County ____________________ State _______ Zip _______________
Mailing Address ________________________________________________City ________________________ County ____________________ State _______ Zip _______________
Telephone: Home _________________ Work _______________ Currently receiving Family Assistance (FA) benefits? Yes ___ No ___ Date last FA check received _______________
Currently in school/training? Yes ___ No ___ Name of School? ____________________________ Circle current classification: FRESHMAN SOPHOMORE JUNIOR SENIOR
Vocational Goal ___________________________ Highest grade completed ________ Length of Course of Study __________ months.
Applicant’s Language_____________
Applicant’s Employer’s Name __________________________________________________ Other Employer’s Name ____________________________________________________
nd
Circle one: Spouse
2
Job
Other Household Member
HOUSEHOLD INFORMATION: List EVERYONE living in the home including applicant, spouse and all children.
Sex
RELATIONSHIP
WAGES
HOURS
UNEARNED INCOME
SSN
TO APPLICANT/
(PAY) PER
WORKED
(Source, Gross Amount & How Often)
SSI, Social Security, Unemployment Comp.,
NAME
(Optional)
DOB
PARENT
HOUR
PER WEEK
Family Assistance, Child Support, etc
1.
2.
3.
4.
5.
6.
7.
DAYS CARE IS NEEDED
WHERE IS CHILD IN CARE NOW?
Where Will Child Receive
NAME OF
(If relative, what relationship)
NAME OF CHILD(REN)
Care If Child Care
SCHOOL CHILD
Center, Church Related Center, Family
WHO NEED CHILD CARE
M
T
W
T
F
S
S
Application Is Approved
ATTENDS
Day Care Home, Relative Care
1.
2.
3.
4.
5.
6.
I certify that the information given is true and complete to the best of my knowledge.
Total Income: _________________ Total Number in the Family: ___________
Applicant Signature: ________________________________________ Date: _____________
CMA Worker Signature: __________________________ Date: _____________
DHR-CMA-1973 (April 2002)
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