Form DHS/CC:1 "Child Care and Early Education Service Eligibility Application" - New Jersey

What Is Form DHS/CC:1?

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

Form Details:

  • Released on December 1, 2008;
  • The latest edition provided by the New Jersey Department of Human Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS/CC:1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form DHS/CC:1 "Child Care and Early Education Service Eligibility Application" - New Jersey

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Child Care and Early Education
Service Eligibility Application
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
Applicant Instructions for Completing the Child Care Eligibility Form
The following instructions are keyed to the various sections of this form. Please read carefully.
INSTRUCTIONS FOR COMPLETING SECTION A
6. List income received from an absent parent for child support or
1. Enter your full name (last, first, middle initial), social security
alimony.
number and date of birth (month/date/year). Check one or more
7. Include any other income received which is required to be listed
of the appropriate boxes provided to indicate your race. Check
for federal and state tax reporting purposes.
the appropriate box to indicate your ethnicity and sex. Check the
appropriate box to indicate the relationship of the parent/
8. Indicate the annual total of all sources of income.
applicant to the child(ren) for which you are making an
INSTRUCTIONS FOR COMPLETING SECTION C
application for assistance. If you are not an immediate relative
(mother/father), please indicate whether you are another legally
Provide Information of Current Work, School and/or Training
responsible person, a foster parent or other. If other, please
Activity for Applicant and Co-Applicant (if applicable).
specify.
1. Enter the name, complete address and telephone number of
2. If applicable (resides in household), enter the full name of your
Primary Work/School/Training Site.
spouse or co-applicant, social security number and date of birth
2. Check the appropriate box to indicate if activity is work, school
(month/date/year). Check the appropriate boxes provided to
indicate the race, ethnicity and sex of the co-applicant/spouse.
or training.
3. Enter your starting date (month/date/year).
3. Enter your home address and county in which you reside. Enter
the school district which the child(ren) attends.
4. Check the appropriate box to indicate if Work/School/Training
activity is full time, part time or seasonal. Enter the number of
4. Enter your home telephone number.
hours per week and months per year spent at site.
5. Enter the “family size” meaning the number of adults (persons
18 years or older who are legally responsible for the children)
5. Include the information for your Secondary Work/School/Training
activity (if applicable).
and dependent adults (persons 18 years or older) who are in
your immediate family unit, and the number of dependent
INSTRUCTIONS FOR COMPLETING SECTION D
children (persons under age 18).
Questions 1-9. Check the appropriate box (either “Yes” or “No”)
Examples: In a single parent family with two children state:
for each question. If you answer “Yes” to any of questions 2-5,
“# of Adults: 1, # of Children: 2.”
provide the requested information.
In a two parent family with a dependent adult (grandparent) and
Questions 10. Check the appropriate box to indicate if you are
two children state: “# of Adults: 3, # of Children: 2.”
applying for assistance because you are ineligible for the TANF or
Note: If as a single parent, you and your child(ren) live with your
TCC programs.
mother and father, you would NOT include the grandparents in
Questions 11. Check whether you understand you are applying
the family size.
for voucher or contracted child care services.
INSTRUCTIONS FOR COMPLETING SECTION B
Questions 12. Check whether all of the children in your family have
health insurance and if you wish to receive an application for NJ
Provide Income Information Based on the Current Year.
Family Care.
Fill In All Blanks. List Gross Figures Unless Otherwise
Indicated. If You Receive None in a Certain Category,
INSTRUCTIONS FOR COMPLETING SECTION E
Write “0.”
1-2. Enter full name (last, first, middle initial), social security number
For each adult (applicant co-applicant or other dependent adult)
and date of birth (month/date/year) for each child for whom
residing in the household unit, list all current income information.
assistance is requested. Check the appropriate boxes provided to
Columns are provided to enter income information either by week,
indicate race, ethnicity and sex of child(ren). Indicate the hours,
every two weeks, month or year. For separated or divorced spouses,
days and duration for which child care is needed. Check the
include only that income (i.e., child support or alimony) which is
appropriate box to indicate if the child(ren) has a special need, if
available to the custodial family.
yes, state the need. Check the appropriate box to indicate if the
child is a US citizen. If yes, attach a copy of the child’s birth certificate
1. List all gross income due to wages and salary.
and social security card. Proof of the child’s citizenship is not
2. List all benefit income received from pensions and retirement.
required for Abbott, Child Protective Services, Kinship or Post-
Adoption sibsidies.
3. List all benefit income received from Supplemental Security
Income (SSI).
INSTRUCTIONS FOR COMPLETING SECTION F
4. List all benefit income received from unemployment and
After reading the certification, applicant and co-applicant (if
workmen’s compensation.
applicable) sign on the appropriate line and include the date.
5. List all benefit income received from public assistance (TANF).
Rev 12/08
Child Care and Early Education
Service Eligibility Application
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
Applicant Instructions for Completing the Child Care Eligibility Form
The following instructions are keyed to the various sections of this form. Please read carefully.
INSTRUCTIONS FOR COMPLETING SECTION A
6. List income received from an absent parent for child support or
1. Enter your full name (last, first, middle initial), social security
alimony.
number and date of birth (month/date/year). Check one or more
7. Include any other income received which is required to be listed
of the appropriate boxes provided to indicate your race. Check
for federal and state tax reporting purposes.
the appropriate box to indicate your ethnicity and sex. Check the
appropriate box to indicate the relationship of the parent/
8. Indicate the annual total of all sources of income.
applicant to the child(ren) for which you are making an
INSTRUCTIONS FOR COMPLETING SECTION C
application for assistance. If you are not an immediate relative
(mother/father), please indicate whether you are another legally
Provide Information of Current Work, School and/or Training
responsible person, a foster parent or other. If other, please
Activity for Applicant and Co-Applicant (if applicable).
specify.
1. Enter the name, complete address and telephone number of
2. If applicable (resides in household), enter the full name of your
Primary Work/School/Training Site.
spouse or co-applicant, social security number and date of birth
2. Check the appropriate box to indicate if activity is work, school
(month/date/year). Check the appropriate boxes provided to
indicate the race, ethnicity and sex of the co-applicant/spouse.
or training.
3. Enter your starting date (month/date/year).
3. Enter your home address and county in which you reside. Enter
the school district which the child(ren) attends.
4. Check the appropriate box to indicate if Work/School/Training
activity is full time, part time or seasonal. Enter the number of
4. Enter your home telephone number.
hours per week and months per year spent at site.
5. Enter the “family size” meaning the number of adults (persons
18 years or older who are legally responsible for the children)
5. Include the information for your Secondary Work/School/Training
activity (if applicable).
and dependent adults (persons 18 years or older) who are in
your immediate family unit, and the number of dependent
INSTRUCTIONS FOR COMPLETING SECTION D
children (persons under age 18).
Questions 1-9. Check the appropriate box (either “Yes” or “No”)
Examples: In a single parent family with two children state:
for each question. If you answer “Yes” to any of questions 2-5,
“# of Adults: 1, # of Children: 2.”
provide the requested information.
In a two parent family with a dependent adult (grandparent) and
Questions 10. Check the appropriate box to indicate if you are
two children state: “# of Adults: 3, # of Children: 2.”
applying for assistance because you are ineligible for the TANF or
Note: If as a single parent, you and your child(ren) live with your
TCC programs.
mother and father, you would NOT include the grandparents in
Questions 11. Check whether you understand you are applying
the family size.
for voucher or contracted child care services.
INSTRUCTIONS FOR COMPLETING SECTION B
Questions 12. Check whether all of the children in your family have
health insurance and if you wish to receive an application for NJ
Provide Income Information Based on the Current Year.
Family Care.
Fill In All Blanks. List Gross Figures Unless Otherwise
Indicated. If You Receive None in a Certain Category,
INSTRUCTIONS FOR COMPLETING SECTION E
Write “0.”
1-2. Enter full name (last, first, middle initial), social security number
For each adult (applicant co-applicant or other dependent adult)
and date of birth (month/date/year) for each child for whom
residing in the household unit, list all current income information.
assistance is requested. Check the appropriate boxes provided to
Columns are provided to enter income information either by week,
indicate race, ethnicity and sex of child(ren). Indicate the hours,
every two weeks, month or year. For separated or divorced spouses,
days and duration for which child care is needed. Check the
include only that income (i.e., child support or alimony) which is
appropriate box to indicate if the child(ren) has a special need, if
available to the custodial family.
yes, state the need. Check the appropriate box to indicate if the
child is a US citizen. If yes, attach a copy of the child’s birth certificate
1. List all gross income due to wages and salary.
and social security card. Proof of the child’s citizenship is not
2. List all benefit income received from pensions and retirement.
required for Abbott, Child Protective Services, Kinship or Post-
Adoption sibsidies.
3. List all benefit income received from Supplemental Security
Income (SSI).
INSTRUCTIONS FOR COMPLETING SECTION F
4. List all benefit income received from unemployment and
After reading the certification, applicant and co-applicant (if
workmen’s compensation.
applicable) sign on the appropriate line and include the date.
5. List all benefit income received from public assistance (TANF).
Rev 12/08
ADDRESS REPLY TO:
The Child Care Resource and Referral Agency located in the
county where you live. A list can be found at:
Child Care and Early Education
http://www.state.nj.us/humanservices/dfd/programs/child/ccrr/
Service Eligibility Application
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
A
Applicant/Co-Applicant Information
Please Read Instructions, Print Clearly, Answer All Questions
1. PARENT/APPLICANT NAME
SOCIAL SECURITY NO.
DATE OF BIRTH
/
/
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacifi c Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
Relationship of
to children:
Father
Mother
Legally Responsible Adult
Foster Parent
Other:
APPLICANT
2. PARENT/CO-APPLICANT NAME
(If Applicable)
SOCIAL SECURITY NO.
DATE OF BIRTH
/
/
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacifi c Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
3. HOME ADDRESS
(Number and Street)
City:
State:
Zip Code:
County:
School District:
4. HOME TELEPHONE:
5. NUMBER OF ADULTS IN FAMILY:
NUMBER OF CHILDREN IN FAMILY:
TOTAL FAMILY SIZE:
Family size includes parent, spouse, children for whom subsidy is requested, other dependent children, or adults claimed on applicant’s or co-applicant’s
IRS 1040. In cases of kinship, family size includes the child for whom subsidy is requested and all dependents claimed on the grandparent’s, aunt’s or
relative’s IRS 1040. For DYFS cases, a child and any of his/her siblings living in the same home and who are in DYFS-paid out of home placement shall
be counted to determine the size of the family.
Attach Original Proof of Income - Most Recent Four Consecutive Weeks
B
Family Income Information
Information is not required for DYFS-paid caregivers. Payments for DYFS children in out of home placement does not count as income.
PARENT/CO-APPLICANT
PARENT/CO-APPLICANT
For each source, enter income information
List gross income for current:
List gross income for current:
either by week, bi-weekly, month or year.
Include child support and/or alimony.
WEEK
2 WEEKS
MONTH
YEAR
WEEK
2 WEEKS
MONTH
YEAR
1. Wages and Salary (gross):
2. Pensions, Retirement:
3. Supplemental/Social Security Benefi ts:
4. Unemployment, Workmen’s Compensation:
5. TANF Cash Assistance:
6. Child Support/Alimony:
7. Other:
8. TOTAL GROSS INCOME:
C
Proof of Current School Registration Must Be Attached
Work/School/Training Information
PARENT/CO-APPLICANT
PARENT/CO-APPLICANT
Name of PRIMARY Work/School/Training Site:
Complete Address (Street, City, State, & Zip):
(If applicable, enter “Self-Employed”)
(
)
(
)
Telephone Number:
Work
School
Training
Work
School
Training
Check One: Enter Starting Date (Mo/Dy/Yr):
/
/
/
/
Start Date
Start Date
Check One and Enter: Number of Hours/
Full Time
Part Time
# Hrs/Wk
Full Time
Part Time
# Hrs/Wk
Week and Months/Year for Work/School/Training
Seasonal Employment
# Mos/Yr
Seasonal Employment
# Mos/Yr
Name of SECONDARY Work/School/Training Site:
Complete Address (Street, City, State, & Zip):
(
)
(
)
Telephone Number:
Work
School
Training
Work
School
Training
Check One: Enter Starting Date (Mo/Dy/Yr):
/
/
/
/
Start Date
Start Date
Full Time
Part Time
# Hrs/Wk
Check One and Enter: Number of Hours/
Full Time
Part Time
# Hrs/Wk
Seasonal Employment
# Mos/Yr
Week and Months/Year for Work/School/Training
Seasonal Employment
# Mos/Yr
* Incomplete Applications Will Not Be Accepted *
DHS/CC:1 (12/2008)
All Questions Must Be Answered. Incomplete Applications Will Not Be Accepted.
D
YES NO
Supporting Documents Must Be Attached For Verification
1. Are you currently participating in the Food Stamp Program?
2. Are you currently receiving/have you received assistance for child care with a Temporary Assistance for Needy Families (TANF) or
Transitional Child Care (TCC) grant through the Work First New Jersey (WFNJ) Program within the last two years? If yes, indicate when
/
/
benefits do/did expire by entering Month, Day and Year
and TANF case number:
3. Is your family an active case with the Division of Youth and Family Services (DYFS) and are the children for whom you are requesting
subsidy residing with you? If yes, please give the name of the office:
4. Are you currently receiving a TANF grant? If yes, please indicate the TANF case number:
5. Do you or a member of your family have a chronic medical problem for which child care is recommended as part of a treatment/rehabilitation
plan? If yes, indicate the name of the individual/agency authorizing the treatment plan and telephone number:
Agency Name:
Telephone #: (
)
6. Are you the head of the household in which you reside?
7. Are you currently homeless or at risk of becoming homeless?
8. Are the children for whom you are requesting child care assistance in a DYFS foster home, DYFS para-foster home, or DYFS pre-adoptive
home. If you are employed or participating in a school or training program, proof must be attached for DYFS purposes.
9. Do you receive any cash or voucher assistance to specifically pay for housing?
10. Are you requesting assistance because the County Welfare Agency/Board of Social Services (CWA/BSS) informed you that you are
ineligible for the Temporary Assistance for Needy Families (TANF) or Transitional Child Care (TCC) Program?
11. I understand that I am applying to the agency for:
VOUCHER payment assistance
CONTRACTED services in a comunity-based center
12. Do all of the children in this family have health insurance benefits?
Yes
No
If NO, do you wish to receive an application for NJ Family Care?
Yes
No
Children
Include Each Child Needing Child Care Service and for Whom Assistance Requested.
E
Information
Use Addendum Form to Provide Information for Addiitonal Children.
FULL NAME OF CHILD NO. 1
SOCIAL SECURITY NO.
DATE OF BIRTH
/
/
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
Indicate the hour/days/duration for which child care is needed:
Child has a special need:
No
Yes
If yes, state special need and attach verification:
Child is a US citizen or a qualified alien?
No
Yes
If yes, attach verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE: Status (Check One):
Denied
Approved
Waiting List
Pending
DYFS USE: (Enter the NJ Spirit Case No.)
Program:
Code:
Component:
/
/
Assessed Co-Payment (Enter and Circle One): $
Wk.
Mo.
Enrollment Date:
FULL NAME OF CHILD NO. 2
SOCIAL SECURITY NO.
DATE OF BIRTH
/
/
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
Indicate the hour/days/duration for which child care is needed:
Child has a special need:
No
Yes
If yes, state special need and attach verification:
Child is a US citizen or a qualified alien?
No
Yes
If yes, attach verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE: Status (Check One):
Denied
Approved
Waiting List
Pending
DYFS USE: (Enter the NJ Spirit Case No.)
Program:
Code:
Component:
/
/
Assessed Co-Payment (Enter and Circle One): $
Wk.
Mo.
Enrollment Date:
FULL NAME OF CHILD NO. 3
SOCIAL SECURITY NO.
DATE OF BIRTH
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
Indicate the hour/days/duration for which child care is needed:
Child has a special need:
No
Yes
If yes, state special need and attach verification:
Child is a US citizen or a qualified alien?
No
Yes
If yes, attach verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE: Status (Check One):
Denied
Approved
Waiting List
Pending
DYFS USE: (Enter the NJ Spirit Case No.)
Program:
Code:
Component:
/
/
Assessed Co-Payment (Enter and Circle One): $
Wk.
Mo.
Enrollment Date:
You May Be Required to Provide Additional Proof of Family Size, Income, Citizenship or Residency to Verify Eligibility.
Supporting Documentation Required May Include Most Current IRS Form 1040, Utility Bill or Birth Certificate.
DHS/CC:2 (12/08)
F
Child Care and Early Education Service Eligiblity Application Certification
READ CAREFULLY BEFORE SIGNING
I (we) hereby certify that all of the information provided is true and correct to the best of my (our) knowledge. I (we) know that submitting
false information about my (our) situation, failing to give the necessary information or causing others to hold back information is
against the law and may subject me (us) to prosecution. I (we) also understand that:
1. Acceptance of child care financial assistance is not for my (our) personal use or expenses and that federal, state and local public
funds are and will be used as payment for costs that are directly associated with services rendered by a child care provider.
2. It is unlawful to obtain financial assistance for child care services by providing any false or misleading information, including but not
limited to information about my eligibility and/or information that relates to child attendance for provider records, sign-in sheets or
voucher payment forms. Examples of unlawful behavior include, but are not limited to:
• Failing to accurately report all sources of my (our) income. Examples include, but are not limited to not reporting multiple
sources of income, or an increase or decrease in wage/salary, child support payments, or alimony, or any other income.
• Failing to accurately report the amount of my income. Examples include, but are not limited to reporting the accurate amount(s)
of income from self-employment; rent from property ownership or changing or altering pay stub information.
• Failing to accurately report the number of household members. Examples include, but are not limited to failing to report that
my spouse or another parent/guardian is living in the household.
• Pre-signing and dating voucher certification forms, sign-in sheets or other provider records used to track and verify child
attendance.
• Failing to accurately verify child attendance on voucher payment records/forms within the reporting timeframes.
3. This information is being given in connection with federal, state and local public funds and will be used through computer matching
programs to confirm the accuracy of my (our) statements and verify my (our) income, resources and need for child care assistance,
as warranted.
4. Providing the requested information, including the Social Security Numbers of Parent(s)/Applicant(s), is voluntary. Agency staff may
use my (our) names and Social Security information with federal and state agencies and other sources deemed necessary for
official examination. However, copies of birth certificates, social security and qualified alien resident cards, if applicable, are
required for all children for whom subsiday services are being requested.
5. Failure to provide or deliberate misrepresentation of required information will result in the denial of my (our) application, termination
of child care benefits to the family and referral to federal, state or local agencies for criminal or civil court action, garnishment of
wages or tax intercept, as well as private claims collection agencies for claims action involving repayment and recovery of funds.
6. Providing false or misleading information in connection with my (our) application for child care financial assistance, and/or failing
to report within ten days any change in my (our) family size or family income or any other circumstances that might change my (our)
eligibility, such as work/school/training status, may result in the termination of my (our) child care subsidy and make me (us)
ineligible to apply for and/or receive subsidized child care for a period of six months for the first violation; for a period of 12 months
for a second violation; and permanent disqualification for the third violation.
7. If I receive financial assistance as a result of false or misleading information, I (we) may be responsible to repay the costs of child
care and may be subject to a civil fine and possible criminal prosecution.
8. I (we) understand that in order to verify my (our) income and service need, an agency representative may need to contact my (our)
employer(s). I (we) hereby authorize my (our) employer(s) to release information regarding my (our) income, pay scale, hours and
schedule of work to the agency to which I am applying.
Parent/Guardian Signature:
Date:
Parent/Guardian Signature:
Date:
Unsigned applications cannot be processed. A copy of this document will be provided to you for your records.
DYFS USE ONLY
DYFS Case Manager Name and Number:
Date:
Note:
/
/
/
/
SAR has been completed; voucher payments for DYFS/CPS child care services are approved for the period
thru
DYFS Voucher Payment Authorization Signature:
Date:
CCR&R or CENTER-BASED CONTRACTED (CBC) PROVIDER USE ONLY:
/
/
Check One:
Initial Application
Re-determination
Certification Date:
Family Size:
Annual Family Income: $
Family’s Total Assessed Co-Payment, if applicable (Enter Amt. and Check One): $
WEEK
MONTH
Check One:
DENIED
APPROVED
PENDING
Staff Member Certification:
Date:
Note:
Name of CCR&R or CBC Provider:
DHS/CC:3 (12/08)
ADDRESS REPLY TO:
Child Care and Early Education
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Service Eligibility Application
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STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
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Parent/Applicant Name:
/
/
Social Security Number:
Date of Birth:
Complete for Each Additional Child for Whom You Are Requesting Subsidy
4
FULL NAME OF CHILD NO. 4
SOCIAL SECURITY NO.
DATE OF BIRTH
/
/
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
Indicate the hour/days/duration for which child care is needed:
Child has a special need:
No
Yes
If yes, state special need and attach verification:
Child is a US citizen or a qualified alien?
No
Yes
If yes, attach verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE: Status (Check One):
Denied
Approved
Waiting List
Pending
DYFS USE: (Enter the NJ Spirit Case No.)
Program:
Code:
Component:
/
/
Assessed Co-Payment (Enter and Circle One): $
Wk.
Mo.
Enrollment Date:
5
FULL NAME OF CHILD NO. 5
SOCIAL SECURITY NO.
DATE OF BIRTH
/
/
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
Indicate the hour/days/duration for which child care is needed:
Child has a special need:
No
Yes
If yes, state special need and attach verification:
Child is a US citizen or a qualified alien?
No
Yes
If yes, attach verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE: Status (Check One):
Denied
Approved
Waiting List
Pending
DYFS USE: (Enter the NJ Spirit Case No.)
Program:
Code:
Component:
/
/
Assessed Co-Payment (Enter and Circle One): $
Wk.
Mo.
Enrollment Date:
6
FULL NAME OF CHILD NO. 6
SOCIAL SECURITY NO.
DATE OF BIRTH
/
/
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
Indicate the hour/days/duration for which child care is needed:
Child has a special need:
No
Yes
If yes, state special need and attach verification:
Child is a US citizen or a qualified alien?
No
Yes
If yes, attach verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE: Status (Check One):
Denied
Approved
Waiting List
Pending
DYFS USE: (Enter the NJ Spirit Case No.)
Program:
Code:
Component:
/
/
Assessed Co-Payment (Enter and Circle One): $
Wk.
Mo.
Enrollment Date:
7
FULL NAME OF CHILD NO. 7
SOCIAL SECURITY NO.
DATE OF BIRTH
/
/
(Last)
(First)
(M.I.)
(9 Digit Number)
(Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
:
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
RACE
Hispanic/Latino:
Yes
No
Male
Female
ETHNICITY:
SEX:
Indicate the hour/days/duration for which child care is needed:
Child has a special need:
No
Yes
If yes, state special need and attach verification:
Child is a US citizen or a qualified alien?
No
Yes
If yes, attach verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE: Status (Check One):
Denied
Approved
Waiting List
Pending
DYFS USE: (Enter the NJ Spirit Case No.)
Program:
Code:
Component:
/
/
Assessed Co-Payment (Enter and Circle One): $
Wk.
Mo.
Enrollment Date:
DHS/CC:2A (12/08)