Child Care Assistance Application

Amy Iversen-Pollreisz

Interim 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

First Name:

Middle:

Last Name:

Mailing Address:

City:

State:

Zip Code:

County:

Address where you live (if different than mailing):

City:

State:

Zip Code:

County:

Home Phone Number: - -

Work Phone Number: - -

HOUSEHOLD INFORMATION

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

Marital Status:

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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
	White/Caucasian Native American/Alaska Native Black/African American Native Hawaiian/Pacific Islander Asian/Oriental	YesNo			- -

White/Caucasian
Native American/Alaska Native
Black/African American
Native Hawaiian/Pacific Islander
Asian/Oriental

YesNo

- -

White/Caucasian
Native American/Alaska Native
Black/African American
Native Hawaiian/Pacific Islander
Asian/Oriental

YesNo

- -

Enter another family member

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

Is any household member active duty in the U.S. Military? YesNo

If yes, please indicate who:

Is any household member in the National Guard or Military Reserve? YesNo

If yes, please indicate who:

Do you receive SNAP benefits? YesNo

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

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.

Do you consider yourself homeless? YesNo

If yes, would you like a referral to services in your community? YesNo

What is the primary language spoken in your home?

Do your family assets exceed $1,000,000? YesNo

Are the children for whom you are requesting assistance:

US Citizens or
Alien in Satisfactory Immigration Status (Please submit copies of immigration documents for each child)

EDUCATION or TRAINING

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

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

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

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.

Place of Work:

Date Employment Began:

Phone: - -

What times do you work? (example 8 am - 5 pm)

Total weekly hours worked:

Hourly wage or salary: $

How often are you paid? WeeklyEvery Two WeeksTwice a MonthMonthly

Enter another job

OTHER INCOME

Do you receive child support payments? YesNo

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.)

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

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

If yes, to whom paid?

Amount paid per month? $

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

(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's Name:

Is this child in school? YesNo

If yes, what hours? (example 8:00-3:15):

Is the child in a pre-school program run through the school district or a Head Start program? YesNo

If yes, please list the name of the program:

Contact Person:

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 Name:

Provider Phone: - -

Provider Address:

City:

Provider ID Number:

Cost of care per child (include if hourly, weekly, etc.):

Type of provider: ?

(if relative, list relationship to child):

Does this provider care for all your children? YesNo

(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?

Enter another child care provider

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