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 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, or an address change.
• I understand that I am responsible for payment of any child care expenses not covered by the Division of Child Care Services.
• 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.