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 .


Visit the Online Child Care Search to locate a registered or licensed child care provider.


Parent or Guardian
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HOUSEHOLD INFORMATION

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



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

Race:







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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 definition of "homeless" according to the McKinney-Vento Act. Review the definition of "homeless" to help in answering the following questions.




Any citizen in the State of South Dakota who meets the voter registration requirements and applies for public assistance must be provided the opportunity to register to vote.

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. (failure to check either box is deemed a declination to register for purposes of receiving assistance in registration but is not deemed a written declination to receive an application. If you do not check either box, you will be provided a voter registration form that you may complete at your convenience.)



EDUCATION or TRAINING

You must include an official 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





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Enter another student

EMPLOYMENT

You must attach proof of income for all current employment:

  • The two most recent pay stubs;
  • A wage verification 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
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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 the last 30 days of payments)

CHILD CARE NEED

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


Child #1
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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
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?
Enter another child care provider