Lynne A. Valenti
Cabinet Secretary

CHILD CARE SERVICES ASSISTANCE APPLICATION

Application Instructions

Read the application carefully and answer each question completely. Refer to the Frequently Asked Questions section for more information.


If you have any questions about completing this application, you can call (605) 773-4766, toll-free 1-800-227-3020, or email CCS@state.sd.us.


If you need to locate a registered or licensed child care provider, click here.



Parent or Guardian
 -  -
 -  -


HOUSEHOLD INFORMATION

List everyone who lives in your home, including roomers, boarders, friends and relatives.



Name (Last, First, Initial) Race (optional)
Check all that apply
Hispanic
or Latino?
Sex Date of
Birth
Social Security
Number (optional)
Relationship




 -  -




 -  -




 -  -

Enter another family member
FEDERAL REGULATIONS GOVERNING THE USE OF CHILD CARE FUNDS REQUIRE A RESPONSE TO THE FOLLOWING QUESTIONS:





If your current address is a temporary living arrangement, you may meet the defintion of "homeless" according to the McKinney-Vento Act. Review the definition of "homeless" to help in answering the following questions.







EDUCATION or TRAINING

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


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

Enter another student
EMPLOYMENT

You must attach proof of income for all current employment:

  • The two most recent pay stubs;
  • 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 your most recent income tax return, including all schedules.

Please fill out the following information for each job.


Employment #1
 -  -
Enter another job
OTHER INCOME

(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.)


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

Enter another source of income

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



CHILD CARE NEED

Fill out the following information for each child in child care.


Child #1
Enter another child
CHILD CARE PROVIDER

If you have more than one child care provider, please fill out the following information for each of them.


Provider #1
 -  -
?
Enter another child care provider


4oiGIFNEIEJJVCBEZXRlY3Rpb24=