Key Services
CHILD CARE SERVICES ASSISTANCE APPLICATION

First Name Middle Last Name
Mailing Address City State Zip Code County
Address where you live (if different than mailing) Home Telephone Number Work Telephone Number
-- -- -- --
Are the children for whom you are requesting assistance ?

(Please submit copies of immigration documents for each child)

HOUSEHOLD


List everyone who lives in your home, including roomers, boarders, friends and relatives. Acceptable codes under "Race" category are listed below (if you are of mixed race, please check all that apply):


Marital Status

Name(Last, First, Initial) Hispanic or Latino ? Sex Date of Birth Social Security Number (optional) Relationship
  -- --
  White/Caucasian        
  Native American/Alaska Native        
  Black/African American        
  Native Hawiian/Pacific Islander        
  Asian/Oriental        
  -- --
  White/Caucasian        
  Native American/Alaska Native        
  Black/African American        
  Native Hawiian/Pacific Islander        
  Asian/Oriental        
  -- --
  White/Caucasian        
  Native American/Alaska Native        
  Black/African American        
  Native Hawiian/Pacific Islander        
  Asian/Oriental        
  -- --
  White/Caucasian        
  Native American/Alaska Native        
  Black/African American        
  Native Hawiian/Pacific Islander        
  Asian/Oriental        
  -- --
  White/Caucasian        
  Native American/Alaska Native        
  Black/African American        
  Native Hawiian/Pacific Islander        
  Asian/Oriental        
  -- --
  White/Caucasian        
  Native American/Alaska Native        
  Black/African American        
  Native Hawiian/Pacific Islander        
  Asian/Oriental        
  -- --
  White/Caucasian        
  Native American/Alaska Native        
  Black/African American        
  Native Hawiian/Pacific Islander        
  Asian/Oriental        
  -- --
  White/Caucasian        
  Native American/Alaska Native        
  Black/African American        
  Native Hawiian/Pacific Islander        
  Asian/Oriental        




EDUCATION or TRAINING


Do you need help paying for child care in order to go to school ?

(You must include an offical school schedule for each adult family member attending school)

Students Name Place of Education or Training Credit Hours Starting Date Ending Date Contact Person Phone Number
-- --
-- --


EMPLOYMENT INCOME


Do you need help paying for child care in order to work ?


You must attach proof of income for all current employment:
  • The two most recent pay stubs for each adult working in the home:
  • A wage verifcation form if you have a new job and have not yet received two pay stubs:
  • If you are self-employed, a complete copy of you rmost recent income tax return, including all schedules.

Please fill out the following information for each job. If you have more than three employers, please attach a seperate sheet of paper listing the smae information.


Employment #1

Place of Work Date Employment Began:   Phone -- --
What days of the week do you work? Mon Tue Wed Thurs Fri Sat Sun
What times do you work? (example 8am-6pm) Total weekly hours worked:
Hourly wage or salary How often are you paid?


Employment #2

Place of Work Date Employment Began:   Phone -- --
What days of the week do you work? Mon Tue Wed Thurs Fri Sat Sun
What times do you work? (example 8am-6pm) Total weekly hours worked:
Hourly wage or salary How often are you paid?


Employment #3

Place of Work Date Employment Began:   Phone -- --
What days of the week do you work? Mon Tue Wed Thurs Fri Sat Sun
What times do you work? (example 8am-6pm) Total weekly hours worked:
Hourly wage or salary How often are you paid?


OTHER INCOME


Do you receive child support payments ? Monthly Amount $

(If you do not receive child support payments through the SD Division of Child Support, you must provide verification of payments received for the six months prior to the date of this application.)

Do you receive food stamps ?
Do you receive Federal rental assistance or live in subsidized housing ?

List any other sources of income you have, including work-study, interest, pensions, retirement, TANF, Social Security, Veteran's Benefits, periodic/lease income, boarder/roomer rent, workers compensation or unemployment.


Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $
Person with Income: Type of Income: Monthly Gross: $


Do you or anyone in your household make court ordered child support payments ?


To Whom Paid? Amount paid per month?


If yes, is the payment made through the SD Division of Child Support Enforcement ?


(If no, provide proof of payment - a cancelled check or a receipt from the clerk of courts)


CHILD CARE NEEDS

Fill out the following information for each child in child care.  If you need more room, please attach a separate piece of paper listing the same information for each additional child.


Childs Name: Is this child in school ?
If yes, what hours ? (example 8:00-3:15) What days ? Mon Tues Wed Thurs Fri
Is the child in a pre-school program run through the school district or a Head Start program?
If yes, please list the name of the program: Contact Person

Childs Name: Is this child in school ?
If yes, what hours ? (example 8:00-3:15) What days ? Mon Tues Wed Thurs Fri
Is the child in a pre-school program run through the school district or a Head Start program?
If yes, please list the name of the program: Contact Person

Childs Name: Is this child in school ?
If yes, what hours ? (example 8:00-3:15) What days ? Mon Tues Wed Thurs Fri
Is the child in a pre-school program run through the school district or a Head Start program?
If yes, please list the name of the program: Contact Person

Childs Name: Is this child in school ?
If yes, what hours ? (example 8:00-3:15) What days ? Mon Tues Wed Thurs Fri
Is the child in a pre-school program run through the school district or a Head Start program?
If yes, please list the name of the program: Contact Person

CHILD CARE PROVIDER

If you have more than one child care provider, please fill out the information for each of them. Please click here for more information about provider types.



Provider #1

Name: Provider Phone: -- --
Provider Address: City:
Provider ID Number Cost of care per child: $
Type of provider
Does this provider care for all your children ? (if no, list those cared for):
What days and hours does this provider care for your children?
When did the provider begin caring for your children?

Provider #2

Name: Provider Phone: -- --
Provider Address: City:
Provider ID Number Cost of care per child: $
Type of provider
Does this provider care for all your children ? (if no, list those cared for):
What days and hours does this provider care for your children?
When did the provider begin caring for your children?