Form HW 2028 Child Care Relationship Form - Idaho

Form HW2028 is a Idaho Department of Health and Welfare form also known as the "Child Care Relationship Form". The latest edition of the form was released in August 1, 2016 and is available for digital filing.

Download an up-to-date Form HW2028 in PDF-format down below or look it up on the Idaho Department of Health and Welfare Forms website.

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Child Care Relationship Form
HW2028 | REV 8/2016
Complete this form when a child who needs Child Care Assistance lives with a caretaker relative or legal guardian, rather
than his or her parents.
How to use this form
1. Complete all fields
2. Attach verifications (if applicable)
3. Submit the form to the Department
Contact the Department
Phone: 1-877-456-1233
Fax: 1-866-434-8278
Mail: P.O. Box 83720, Boise, ID 83720-0026
Local office: healthandwelfare.idaho.gov
Tell us about the child(ren) applying for Child Care Assistance
Child First Name
Child Middle Name
Child Last Name
Child Date of Birth
Tell us about yourself and your relationship to the child(ren)
Middle Name
Last Name
First Name
Choose one:
How are you related the child(ren)?
I am a caretaker relative (not a parent) of the child(ren) listed above.
I am the legal guardian of the child. *You must supply legal documentation verifying guardianship.
Tell us about the rest of your household
Please list the following people on the table below: your spouse, your children (under age 18), and any children (under age 18) related to the
child(ren) listed above. Tell us each person’s relationship to you and how they are related to the child(ren) applying for assistance.
First Name
Last Name
Relationship to you
Is this person related to the child(ren) above?
No
Yes. If yes, how?
No
Yes. If yes, how?
No
Yes. If yes, how?
No
Yes. If yes, how?
Signature
(Must be completed)
Under penalty of perjury, I swear or affirm the information I have provided is true and complete.
Caretaker Relative/Legal Guardian Printed Name
Caretaker Relative/Legal Guardian Signature
Date
Child Care Relationship Form
HW2028 | REV 8/2016
Complete this form when a child who needs Child Care Assistance lives with a caretaker relative or legal guardian, rather
than his or her parents.
How to use this form
1. Complete all fields
2. Attach verifications (if applicable)
3. Submit the form to the Department
Contact the Department
Phone: 1-877-456-1233
Fax: 1-866-434-8278
Mail: P.O. Box 83720, Boise, ID 83720-0026
Local office: healthandwelfare.idaho.gov
Tell us about the child(ren) applying for Child Care Assistance
Child First Name
Child Middle Name
Child Last Name
Child Date of Birth
Tell us about yourself and your relationship to the child(ren)
Middle Name
Last Name
First Name
Choose one:
How are you related the child(ren)?
I am a caretaker relative (not a parent) of the child(ren) listed above.
I am the legal guardian of the child. *You must supply legal documentation verifying guardianship.
Tell us about the rest of your household
Please list the following people on the table below: your spouse, your children (under age 18), and any children (under age 18) related to the
child(ren) listed above. Tell us each person’s relationship to you and how they are related to the child(ren) applying for assistance.
First Name
Last Name
Relationship to you
Is this person related to the child(ren) above?
No
Yes. If yes, how?
No
Yes. If yes, how?
No
Yes. If yes, how?
No
Yes. If yes, how?
Signature
(Must be completed)
Under penalty of perjury, I swear or affirm the information I have provided is true and complete.
Caretaker Relative/Legal Guardian Printed Name
Caretaker Relative/Legal Guardian Signature
Date

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