The signature page must be signed, and returned to the Child Care Services, Department of Social Services, 910 E Sioux Ave, Pierre, SD 57501-3940 by 9/26/2021.

Application ID:
Applicant Name:

Please read each bullet and sign at the bottom of this page.

• I declare under the penalties of perjury that this application is true and correct.
• I understand that it is my responsibility to provide proof of income and other requested information needed to determine eligibility for this program and that failure to do so can result in my application being denied.
• I understand that if determined eligible, it is my responsibility to notify Child Care Services in writing within ten (10) days whenever I have a permanent change in employment or school status, a change in child care providers or child care arrangements, an address change, or if my monthly gross household income exceeds the limit defined on the back of the child care certificate.
• I understand that I am responsible for payment of any child care expenses not covered by the Division of Child Care Services and that failure to pay may mean loss of my child care benefits.
• I understand that if I receive assistance to which I am not entitled as a result of providing false information, I must repay the cost of that assistance.
• I understand that I have the right to appeal any decision made by Child Care Services and that the request must be made within 30 days of my denial or benefit notice.