Form FIA-1100 "Work Schedule for Child Care" - New York City

What Is Form FIA-1100?

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

Form Details:

  • Released on December 27, 2016;
  • The latest edition provided by the New York City Department of Social Services;
  • Easy to use and ready to print;
  • Available in Haitian Creole;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FIA-1100 by clicking the link below or browse more documents and templates provided by the New York City Department of Social Services.

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Download Form FIA-1100 "Work Schedule for Child Care" - New York City

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FIA-1100 (E) 12/27/2016 (page 1 of 2)
LLF
Work Schedule For Child Care
You must complete this form to get child care. This form asks about your employer and
the days and hours you work. If the days and hours you work change often, give the days
and hours you work the most.
Applicant/Participant's Name:
Cash Assistance Case Number:
Employer's Name:
Employer's Address:
Work Location if Different from Employer's Address:
If the work location is in New York City, answer the following question to the best of your
knowledge.
The employer has a total of
11 or more employees
10 or fewer employees
Weekly Schedule
Days
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
Start
Time:
Total
End
Weekly
Time:
hours
worked:
Number
of hours
worked:
Total Weekly Travel Time: If your travel time changes each day, use your longest travel
time and multiply by five (5). For example: Two (2) days a week your travel time is two (2)
hours, and three (3) days a week your travel time is one (1) hour, your total travel time
should be 5x2 = 10 Hours.
Total Weekly Travel Time:
FIA-1100 (E) 12/27/2016 (page 1 of 2)
LLF
Work Schedule For Child Care
You must complete this form to get child care. This form asks about your employer and
the days and hours you work. If the days and hours you work change often, give the days
and hours you work the most.
Applicant/Participant's Name:
Cash Assistance Case Number:
Employer's Name:
Employer's Address:
Work Location if Different from Employer's Address:
If the work location is in New York City, answer the following question to the best of your
knowledge.
The employer has a total of
11 or more employees
10 or fewer employees
Weekly Schedule
Days
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
Start
Time:
Total
End
Weekly
Time:
hours
worked:
Number
of hours
worked:
Total Weekly Travel Time: If your travel time changes each day, use your longest travel
time and multiply by five (5). For example: Two (2) days a week your travel time is two (2)
hours, and three (3) days a week your travel time is one (1) hour, your total travel time
should be 5x2 = 10 Hours.
Total Weekly Travel Time:
FIA-1100 (E) 12/27/2016 (page 2 of 2)
Human Resources Administration
LLF
Family Independence Administration
Work Schedule For Other Adults in Household
Relationship to Child:
Parent
Guardian
Applicant/Participant's Name:
Cash Assistance Case Number:
Employer's Name:
Employer's Address:
Work Location if Different from Employer's Address:
If the work location is in New York City, answer the following question to the best of your
knowledge.
The employer has a total of
11 or more employees
10 or fewer employees
Weekly Schedule
Days
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
Start
Time:
Total
End
Weekly
Time:
hours
worked:
Number
of hours
worked:
Total Weekly Travel Time: If your travel time changes each day, use your longest travel
time and multiply by five (5). For example: Two (2) days a week your travel time is two (2)
hours, and three (3) days a week your travel time is one (1) hour, your total travel time
should be 5x2 = 10 Hours.
Total Weekly Travel Time:
I swear or affirm that the Information on this form is true and correct.
Applicant/
Participant’s Signature: _______________________________ Date: _______________
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