Need Assistance with Child Care

SUGGESTED ELIGIBILITY DOCUMENTS

Proof of Age and Identity of Student-Examples include: Birth Certificate Valid Unexpired Passport Hospital Certificate (proof of live birth) with name of child and parent Parents’ notarized affidavit Birth Registration, or other legal or notarized identification for child’s identity and date of birth verification	Proof of relationship to student- Examples include: Birth certificate of child which identifies the parents Court Order Separation Agreement or Divorce Decree Other legal form of identification
Proof of Identity of Person Enrolling Student and Relationship to Student—Examples of proof of identity with a photograph include: Driver’s License Passport Motor Vehicle ID Card Other legal form of identification	Proof of Family Income (all adults in family)— Examples include: Tax return -1040, W2s, Schedule C/1099 Pay stubs Notarized Employment Letter Notarized letter of no income Military Income Proof of additional income (TCA letter, child support, rental income, unemployment verification, etc.)
Proof of Residency If homeowner, an acceptable document is a current property tax bill or utility bill with property address If renter, an acceptable document is a current rental lease. If the original term of the lease has expired, a copy of a current utility bill with property address or a lease extension should be provided, if applicable. If shared housing with a homeowner or renter who has bona fide residence in the County, notarized documentation must be provided.	Additional Criteria for Prekindergarten Expansion Grant Program Eligibility Only: Homeless with documentation and verification Child with current Individualized Education Program (IEP) or Extended IFSP Child in which English is not the primary language spoken in the home and two or more responses on the Home Language Survey list a language other than English. (Students should not be screened for ELD services at this time.)

Note:
Documentation of income for Prekindergarten students is required for all children, including children experiencing homelessness, children with an IEP or Extended IFSP, and children from homes in which English is not the primary spoken language.

Meeting Income Eligibility is not a requirement in the Prekindergarten Expansion Grant Slots for the following:

Child experiencing homelessness with documentation and verification
Child with current IEP or Extended IFSP
Child in which English is not the primary language spoken in the home and two or more responses on the Home Language Survey list a language other than English. (Students should not be screened for ELD services at this time.)

PREKINDERGARTEN INCOME ELIGIBILITY FORM

1. ALL HOUSEHOLD MEMBERS. List all people living in the household including all children. List all current household income, where applicable, before expenses and deductions for taxes, etc., and how often it is paid: weekly (wk), every two weeks (bi-wk), twice a month (twice), or monthly (mo). If your income varies, write the amount you usually earn. Use additional paper if needed. Note: Parents/Guardians should submit one month of consecutive pay stubs and they must be submitted within 30 days of this application.

Household Member #1

Name:(Required)

First Last

Relationship to Child:(Required)

Birth Date:(Required)

Earnings from Work before deductions Job 1

Amount:(Required)

How Often:(Required)

Earnings from Work before deductions Job 2

Amount:

How Often:

All Other Income Child Support, Alimony, TCA, Disability, Social Security; financial support

Amount:(Required)

How Often:(Required)

(please write n/a if this does not apply to you)

Household Member #2

Name:

First Last

Relationship to Child:

Birth Date:

Earnings from Work before deductions Job 1

Amount:

How Often:

Earnings from Work before deductions Job 2

Amount:

How Often:

All Other Income Child Support, Alimony, TCA, Disability, Social Security; financial support

Amount:

How Often:

Household Member #3

Name:

First Last

Relationship to Child:

Birth Date:

Earnings from Work before deductions Job 1

Amount:

How Often:

Earnings from Work before deductions Job 2

Amount:

How Often:

All Other Income Child Support, Alimony, TCA, Disability, Social Security; financial support

Amount:

How Often:

Household Member #4

Name:

First Last

Relationship to Child:

Birth Date:

Earnings from Work before deductions Job 1

Amount:

How Often:

Earnings from Work before deductions Job 2

Amount:

How Often:

All Other Income Child Support, Alimony, TCA, Disability, Social Security; financial support

Amount:

How Often:

Household Member #5

Name:

First Last

Relationship to Child:

Birth Date:

Earnings from Work before deductions Job 1

Amount:

How Often:

Earnings from Work before deductions Job 2

Amount:

How Often:

All Other Income Child Support, Alimony, TCA, Disability, Social Security; financial support

Amount:

How Often:

Household Member #6

Name:

First Last

Relationship to Child:

Birth Date:

Earnings from Work before deductions Job 1

Amount:

How Often:

Earnings from Work before deductions Job 2

Amount:

How Often:

All Other Income Child Support, Alimony, TCA, Disability, Social Security; financial support

Amount:

How Often:

Household Member #7

Name:

First Last

Relationship to Child:

Birth Date:

Earnings from Work before deductions Job 1

Amount:

How Often:

Earnings from Work before deductions Job 2

Amount:

How Often:

All Other Income Child Support, Alimony, TCA, Disability, Social Security; financial support

Amount:

How Often:

Household Member #8

Name:

First Last

Relationship to Child:

Birth Date:

Earnings from Work before deductions Job 1

Amount:

How Often:

Earnings from Work before deductions Job 2

Amount:

How Often:

All Other Income Child Support, Alimony, TCA, Disability, Social Security; financial support

Amount:

How Often:

2. SIGNATURE. I certify that all the above information is true and that all income is reported. I understand that this information is being given for the school’s receipt of state funds; that school officials may verify the information. Falsification of any information submitted may be cause for rejection of this application or removal from the program after placement.

Signature, Adult in Household:(Required)

Date:(Required)

Total Number of Household Members (Family Size):(Required)

Total Family Annual Household Income:(Required)

Percentage of FPG:

3. SIGNATURE OF Provider Official Reviewing Documentation

Date / /

Need Assistance with Child Care

PREKINDERGARTEN INCOME ELIGIBILITY FORM

Household Member #1

Household Member #2

Household Member #3

Household Member #4

Household Member #5

Household Member #6

Household Member #7

Household Member #8

QUICK LINKS

LOCATION

Have Questions?