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Application for Child Care Services ! Completion of this application does not guarantee you will receive child care assistance. x! x! ! Teen Parents: Do not include information about your parents even if you live with them. Section 1: Applicant Information ! ! !!J1! ! F%()BL! P%8BL! F%()BL! P%8BL! F1.3()BL! F1.3()BL! County Use Only Address Verified? How Verified? Contact Information*: !Please complete at least one S1-$!7A13$L! Q1+@!7A13$L!! =1'%#$!7A13$L!! Other Information: !!J1! E"JNH! !!J1! !!J1! !!J1! ---PAGE BREAK--- You MUST answer all YES or NO questions, sign and date this form. Any question answered with N/A will be considered incomplete and may delay application processing ) Section 2: Primary Adult Caretaker * (same as Applicant, Section 1) Last Name*: First Initial: Social Security Number (optional): Date of Birth*: )Age: Gender*:)))) )))3,412,) ) County Use Only How Verified? Citizenship Status: ))F989G,7)) ))?@7$H989G,7)) ))IJ129=9,6)A29,7)) Marital Status:)) )01<<9,6L)M9-97D)N.OP@JQ,))))))) )E96@N,6.E96@N,<) Ethnicity (optional): ))U9QP179H))))))))) Race (optional, all that apply): )A4,<9H17)576917)@<)A21QW17) )AQ917)) )?189-,)U1N19917)@<)C1H9=9H)5Q2176,<) Highest Grade Completed*:))) )AQQ@H918,)K,D<,,)))) )Z7W7@N7) ACTIVITY[))FS,HW)122)8S18)1PP2:)8@)8S9Q)9769-96J12))) )K9Q1B2,6)) )\4P2@:,6) )O,2=$\4P2@:,6) )X\K.U9DS)OHS@@2)K9P2@41) )\2,4,781<:)OHS@@2)) )],,7)C1<,78)\6JH189@7)) )\7D29QS)1Q)1)Q,H@76)217DJ1D,)) )]<19797D.\6JH189@7)) )C@Q8$O,H@761<:)OHS@@2)) )09662,).)^<_)U9DS) )C1:)FS926)OJPP@<8))) ҏ+,H,9-,)FS926)OJPP@<8) ) ---PAGE BREAK--- You MUST answer all YES or NO questions, sign and date this form. Any question answered with N/A will be considered incomplete and may delay application processing ) Section 3: Additional Individual in your Household * (Adult or Child) ))01234,5,)617)844)89:45;)8<9)=>?497,<)?<)@1:7) Last Name*: First Name*: Middle Initial: Date of Birth*: Age: County Use Only How Verified? Social Security Number (optional): County Use Only How Verified? Gender*:)))) )))L,284,) County Use Only How Verified? Citizenship Status*: ))N:84?6?,9) Marital )I?91R,9.I?91R,7) Ethnicity (optional): )W,417)O,H7,,))) )W,=X)844)5>85)8334@)51)5>?;)?<9?-?9:84))) )O?;8F4,9)) )\2341@,9) )S,46$\2341@,9) )Y\O.V?H>)S=>114)O?34128) )\4,2,<587@)S=>114)) )G1;5$S,=1<987@)S=>114)) O1)`1:a) )G8@)0>?49)S:33175))) ҏ+,=,?-,)0>?49)S:33175) ) ! 0TG`)]VJS)GEY\)ES)D\\O\O)LT+)EOOJ]JTDEQ)VTWS\VTQO)K\KA\+S)))) ---PAGE BREAK--- You MUST answer all YES or NO questions, sign and date this form. Any question answered with N/A will be considered incomplete and may delay application processing " Section 4: Relationship Detail* 01234,5,)617)844)9:;9-9;<84=)49=5,;)9:)>,?591:=)&)8:;)@) Primary Adult Caretaker Name*: ) ) List all other individuals in the household*: What is the Relationship to the Primary Adult Caretaker*? Is this a child who is part of a Joint Custody agreement or another case*? ) ) ) ) ) ) ) ) ) ) ) ) ) ) County Use Only C,7969?8591:D ) ) Section 5: Children’s Care Request and Immunization Records*)01234,5,)617)844)?E94;7,:)49=5,;)9:)>,?591:)@) Are You Requesting Care for this Child*? If you are requesting care, does this child have age- appropriate immunizations*? County Use Only) Verified? How Verified? Child Name: ) )B1F)G:)I71?,==) )B1F)+,49J91<=)+,8=1:) )B1F)K,;9?84)+,8=1:) Not available Pending Verbal Verification Written Verification Dr/Nurse statement Provider School Age Shot Record) Child Name: ) )B1F)G:)I71?,==) )B1F)+,49J91<=)+,8=1:) Not available Pending Verbal Verification Written Verification Dr/Nurse statement Provider School Age Shot Record) Child Name: ) )B1F)G:)I71?,==) )B1F)+,49J91<=)+,8=1:) Not available Pending Verbal Verification Written Verification Dr/Nurse statement Provider School Age Shot Record) Child Name: ) )B1F)G:)I71?,==) )B1F)+,49J91<=)+,8=1:) Not available Pending Verbal Verification Written Verification Dr/Nurse statement Provider School Age Shot Record) Child Name: ) )B1F)G:)I71?,==) )B1F)+,49J91<=)+,8=1:) Not available Pending Verbal Verification Written Verification Dr/Nurse statement Provider School Age Shot Record) Child Name: ) )B1F)G:)I71?,==) )B1F)+,49J91<=)+,8=1:) Not available Pending Verbal Verification Written Verification Dr/Nurse statement Provider School Age Shot Record) ) ---PAGE BREAK--- You MUST answer all YES or NO questions, sign and date this form. Any question answered with N/A will be considered incomplete and may delay application processing ) Section 6: Applicant Employment and Wage Detail Information*: (If applicable) 01234,5,)6,75819)!):1;),<7=),2341>,?)1@;)=1@A,=14?)<9?),<7=)34<7,)1:),2341>2,95 Applicant Name*: Employment Begin Date*: Employment End Date: Are you the Primary Adult Caretaker*? )C1) Are you Self-Employed*? )C1))))))))))))))D:)>,AE):844)1@5)6,75819)FG)H?@45)0<;,52,95)JK3,9A,A)L,5<84) Employer Name*: Doing Business As: Employer Address: City*: State: ZIP: How frequently are you paid*? (Select one) Is this a New Job*? )C1) D:)>,AE):8;A5)M<>)L<5,G) # Hours Worked*: Per: Tips/Commissions/ Bonuses: $ Per: Gross Amount Before Taxes and Deductions*: $ Per: Is this Employment Temporary or Seasonal*? )C1) Estimated End Date: County Use Only Verification Type Pay Date Frequency Hours Worked Hours Care Needed Calculated Pay Rate Per Hour: Tips/Commissions/ Bonuses: Gross Income Before Taxes and Deductions: ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) L1)>1@),K3,75)<9>)T;,1@;),2341>2,95UG)))) 01234,5,)8:)>,AG) Maternity School Break/Temporary Layoff / ) Section 7: Applicant Work Schedule*: 01234,5,)5=8A)A,75819):1;),<7=),?)1;) 6,4:$J2341>,?\)89)H758-85>)))))) Name*: J::,758-,)X,Y89)L<5,UG) ) J::,758-,)J9?)L<5,G) ) 01/23*" 1% 7% 1% 7% 1% O19]) 6<5]) 6@9]) 67=,?@4,U) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) County Use Only How Verified? ) ) ) ---PAGE BREAK--- You MUST answer all YES or NO questions, sign and date this form. Any question answered with N/A will be considered incomplete and may delay application processing ) Section 8: Other Income*: (If applicable) 01234,5,)678192:5617)67);,<5617)%)819),:<=)3,9>17)67)?1@9)=1@>,=14A Individual Name*: ) ) ) ) B88,<56-,)C,D67)E:5,FG) ) ) B88,<56-,)B7A)E:5,G) E1,)I)*68) :3346<:J4,/G) ) ) K7<12,);1@9<,)*8912)J,41L/G) ) M91>>)N21@75G) O1L)P85,7)6>)5=6>)67<12,) 9,<,6-,AQ) ) ) Non-Work Income Types*: ;1<6:4);,<@965?)*;@9-6-19R>S)E6>:J6465?S)+,569,A/) T7,2341?2,75)0123,7>:5617) +,569,2,75)19)U,7>617)*V15);;/) K7>@9:7<,.W:L>@65);,554,2,75)U91<,,A>) K75,9,>5)17)>:-67D>S)0E>S)K+N>S)'("X>) E6-6A,7A>)8912)>51):7A)J17A>) +:6491:A)+,569,2,75)C,7,865>) Y,5,9:7R>)C,7,865>) ) )V1) )V1) ) N77@65?) 0:>=)017596J@5617>) N46217?.[:675,7:7<,) W,:>,)J17@>.91?:456,>) [6465:9?)N44152,75) ;596H,)C,7,865>) \9@>5)K7<12,) N2,96<193)K7<12,) ]19H,9R>)0123,7>:5617) ) ) )V1) )V1) ) Other Income Types*: 01419:A1)]19H>.\NV^)<:>=):>>6>5:7<,) W1L$K7<12,)B7,9D?)N>>6>5:7<,)*WBNU/) ;@334,2,75:4);,<@965?)K7<12,)*;;K/) ) )V1) ) [,A6<:6A.0OU_)N>>6>5:7<,) P4A)ND,)U,7>617) ^11A)N>>6>5:7<,) P5=,9)*E,><96J,)@7A,9)K7A6-6A@:4/) ) )V1) ) Section 9: Adult Caretaker Self-Employed Expenses Detail*: (If applicable) 01234,5,);,<5617)`)819),:<=) NA@45)0:9,5:H,9)46>5,A)67);,<5617>)&):7A)a)L=1)6>);,48$B2341?,A) Name*: County Use Only ) Bb3,7>,)E:5,FG) ^9,c@,7,)N21@75FG) Verified? How Verified?) ) ) ) ) Not available Pending Verbal Verification Written Verification) ) ) ) ) ) Not available Pending Verbal Verification Written Verification) ) ) ) ) ) Not available Pending Verbal Verification Written Verification) ) ) ) ) ) Not available Pending Verbal Verification Written Verification) ) ) Section 10: Teen Parent Education Detail*: (If applicable) )01234,5,);,<5617)"()819),:<=)\,,7)U:9,75)46>5,A)67) ;,<5617>)&):7A)a)L=1)2:9H,A)d\,,7)U:9,75)BA@<:5617e)67)N<56-65? ) Name*: Number of Credits*: School Name*: School Type*: MBE.O6D=);<=114) )[6AA4,);<=114).)f9g)O6D=) Anticipated Completion Date: ) County Use Only Verified? Not Available Pending Verbal Written How Verified? ) ) ) ---PAGE BREAK--- You MUST answer all YES or NO questions, sign and date this form. Any question answered with N/A will be considered incomplete and may delay application processing ) Section 11: Adult Caretaker Training/Education Detail*: (If applicable) 01234,5,)6,75819)""):1;),<7=)>?@45) 0<;,5758-85J Name*: Effective Begin Date*: Effective End Date: Number of Credits*: Training Institution*: Type of Training*: >?@45)K758-85J Name*: H::,758-,)K,G89)O<5,TU) ) H::,758-,)H9?)O<5,U) ) HV<234,U) 67=,?@4,U) P1@;BU) Mon. (am/pm) 8:00 - 5:00 9 Tues. (am/pm) 8:00 - 3:00 7 Weds. (am/pm) 8:00 - 5:00 9 Thurs. (am/pm) 8:00 - 3:00 7 Fri. (am/pm) 8:00 - 5:00 9 Sat. 0 0 Sun. 0 0 O?@45)0<;,5758-85J Name*: Disability Reported Date*: Disability End Date: ) Disability F,231;<;J) Review Due Date, if applicable:) Is this Individual able to take care of children*? ) County Use Only Verified? Not Available Pending Verbal Written) How Verified? ) ) ) ) ) ) ) ) ) ) ---PAGE BREAK--- You MUST answer all YES or NO questions, sign and date this form. Any question answered with N/A will be considered incomplete and may delay application processing ) Section 14: Child Disability Detail*: (If applicable)))01234,5,)6,75819)"'):1;),<7=)7=84>)89)?1@;)=1@A,=14>)89) 6,75819)B)C=1)2<;D,>)EF8AH)89)I758-85? " Name*: Disability Reported Date*: Disability End Date: Disability K,231;<;?) Review Due Date, if applicable:) County Use Only Verified? Not Available Pending Verbal Written How Verified? ) ) Section 15 : Adult Caretaker Paying Child Support Detail*: (If applicable) 01234,5,)6,75819)"#):1;),<7=) I>@45)0<;,5)B)C=1)2<;D,>)EJ)6@331;5H)89)I758-85? Name*: Effective Begin Date*: Effective End Date: Docket/Court Case Recipient Name*: How often is the amount paid*? Amount of Court Ordered Child Support Paid*: County Use Only Verified? Not Available Pending Verbal Written How Verified? ) ) ) ) Section 16 : Child Support Received Detail*: (If applicable) 01234,5,)6,75819)"!):1;),<7=)7=84>)48A5,>)89)6,75819) B)C=1);,7,8-,A)0=84>)6@331;5)3.1;)=)C85=)<9)4,AA)1:)7=84>)7<;,) ,48Q8G8485?)unless there is good cause.))) x) R1;)21;,)>,5<84AS)34,)0<;,)IAA8A5<97,)J;1Q;<2)1::87,L))) County Use Only Non-Custodial Parent Name: SSN Non-Custodial Parent DOB: State ID: Visitation? Open Child Support Case? Paying? Good Cause? )N1)))TU34<89 ) ) ---PAGE BREAK--- You MUST answer all YES or NO questions, sign and date this form. Any question answered with N/A will be considered incomplete and may delay application processing ) Section 18: Adult Caretaker/Job Search Detail*: (if applicable) 01234,5,)6,75819)"%):1;),<7=)>?@45)0<;,5758-85I Name*: J::,758-,)K,L89)M<5,NO) ) J::,758-,)J9?)M<5,O) ) P=<5)<;,)I1@;)F1G)6,<;7=)>758-858,BNQ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) County Use Only Verified? Not Available Pending Verbal Written How Verified? ) ) ) Section 19: Applicant Job Search Schedule*: 01234,5,)5=8B)B,75819):1;),<7=)758-85I Name*: J::,758-,)K,L89)M<5,NO) ) J::,758-,)J9?)M<5,O) ) JR<234,O) 67=,?@4,O) S1@;BO) Mon. (am/pm) 8:00 - 5:00 9 Tues. (am/pm) 8:00 - 3:00 7 Weds. (am/pm) 8:00 - 5:00 9 Thurs. (am/pm) 8:00 - 3:00 7 Fri. (am/pm) 8:00 - 5:00 9 Sat. 0 0 Sun. 0 0 M)89)6,75819)#)?=1)@1A)89>87<5,>)B@,CD)@1A) <;,);,EA,C589F)7<;,G HIJKL))M4,)7=84>NC)C7=114)7<4,9><;.C7=,>A4,O)) Child's Name*: K::,758-,)P,F89)Q<5,OL) ) K::,758-,)K9>)Q<5,L) ) Provider Name*: Provider Address*: # 12034+# 1% 7% 1% 7% 1% R19S) JA,CS) T,>CS) J=A;CS) U;8S) 6<5S) 6A9S) 67=,>A4,O) ) ) ) ) ) ) ) ) ) ) V)W1A;CO) ) ) ) ) ) ) ) ) ) ) 01A95@)XC,)I94@) 0=84>NC)YF,)<5)582,)1:)<33487<5819L)) 0<;,)Z,-,4)<5)582,)1:)Y33487<5819L) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ---PAGE BREAK--- ! ! Authorization to Supply Information % % % % x% x% x% % x% x% x% % % % % % % % % % % % % % % % % % % % % % % % % % % Authorization to Release Information % x% x% x% x% x% % % % % % % % % % % % % % % % % % % % % % % % % ---PAGE BREAK--- ! ! ! ! YOU MUST ALSO READ AND SIGN THIS PAGE ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! IMPORTANT REMINDERS: A person found to have intentionally given false information by deed or omission cannot get child care assistance in Colorado for twelve (12) months for the first offense, twenty-four (24) months for the second offense, and permanently for the third offense. This crime is subject to prosecution under federal and state laws. You must report ! A Change of Eligibility ! Until you are ! After you are ! To remain ! You must use your CCAP ---PAGE BREAK--- ! ! RIGHT OF APPEAL AND FAIR HEARING ! i! i! i! ! ! ! ! of Administrative Courts 633-17th St, 13th Floor Denver, CO 80202 ! G9! ! M9! ! O9! ! ! Discrimination ! ! L-17-,6!J%4%,*'%!XYGUO! ;MYM>!XOOZGYGO!%,!;MYM>!XOOZMOMU!;PLL>! ! ! Keep this page for your reference. ---PAGE BREAK--- ! ! You must submit the following documentation in order to complete your application: DOES THIS APPLY TO YOU? What you need to submit Other Notes A Checklist for Your Use YOU OR OTHER ADULTS IN THE HOUSEHOLD ARE WORKING: 3*30*),>#4$D*#32)*#'4$6#26*#@20E# # YOU OR OTHER ADULTS ARE SELF-EMPLOYED: F*)B1B($'B26#21#G*"1H83."2/3*6'#,'$'&,E#G*"1H*3."2/3*6'# ,*"1H*3."2/3*6'#B6(23*E # YOU OR OTHER ADULTS IN THE HOUSEHOLD JUST STARTED YOUR JOB: # # YOU LOSE YOUR JOB / OR YOU ARE LOOKING FOR A JOB: L20#G*$)(4#M4B"%#M$)*#B,#$D$B"$0"*#26#$#NOPOQ8R#0$,B,#$6%#/2&# # YOU PAY CHILD SUPPORT TO SOMEONE OUTSIDE YOUR HOUSEHOLD: B6(23*E# # YOU HAVE NON-WORK OR OTHER INCOME FROM ANY SOURCE: # # YOU ARE ATTENDING SCHOOL OR TRAINING: Not all counties provide child care while attending school or training. Check with your county for its policy. # # YOU HAVE CHOSEN A PROVIDER AND YOU HAVE CHILDREN REQUESTING CARE: F*)B1B($'B26#21#*$(4#(4B"%Y,#B%*6'B1B($'B26C#0B)'4#%$'*C#(B'BZ*6,4B.C# $6%#B33&6BZ$'B26#)*(2)%,# # YOUR COUNTY NEEDS VERIFICATION OF THE ADDRESS OF YOUR RESIDENCE, REPORTED ON YOUR APPLICATION (IN SECTION 1) [2&,'#.)2DB%*#26*#2)#32)*#21#'4*#12""2