Fillable APPLICATION FOR Home Phone No. Montgomery County, Maryland (Montgomery County Maryland)

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APPLICATION FOR Home Phone No. Montgomery County, Maryland (Montgomery County Maryland)

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The APPLICATION FOR Home Phone No. Montgomery County, Maryland (Montgomery County Maryland) form is 3 pages long and contains:

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  • 149 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Montgomery County Maryland

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TELL US ABOUT YOUR ACTIVITY
APPLICATION FOR
THE WORKING PARENTS ASSISTANCE PROGRAM (WPA)
7300 Calhoun Place Suite 700
Rockville, Maryland 20855
Montgomery County, Maryland
Case ID #________________
Worker’s Initials___________
DEADLINE DATE
Last Name
First Name
Social Security No.
Street Address
Cell Number
Date of Birth
Sex (M, F)
Middle Initial
TELL US ABOUT YOUR MATE /SPOUSE LIVING WITH YOU
Last Name
First Name Middle Initial
Mate’s Social Security No.
City
MARYLAND
Zip Code
Marital Status (single, married,
living w/other parent)
Have you applied for WPA
subsidy before?
Date of Birth
TELL US ABOUT YOURSELF
Employer Name
Address
Employer Name
Address
Telephone
Telephone
Days of the Week Worked
Days of the Week Worked
Time Schedule
Time Schedule
Name of School (IF ATTENDING)
Name of School (IF ATTENDING)
Graduate ____ Undergraduate ___ Vocational ___ High School ___
Graduate ____ Undergraduate ___ Vocational ___ High School ___
Address
Address
Full Time ____ Part Time ____ Current Semester _____________
Full Time ____ Part Time ____ Current Semester
______________
COMPLETE THE INFORMATION FOR ALL OF YOUR CHILDREN (INCLUDE ALL OF YOUR CHILDREN)
Name of Child
Child’s Date of
Birth
Child’s Social Security Number
Relation
to You
Check for
Part Time
Care
Check for
Full Time
Care
COMPLETE THE INFORMATION FOR YOUR CHILDREN’S ABSENT PARENT(S) (INCLUDE ALL ABSENT PARENTS)
Name of Child
Name of Child’s
Absent Parent
Absent Parent’s
Date of Birth
Absent Parent’s
Social Security
Open Child Support Case or
Divorce Decree with Order? Yes, No
EG9/5/18
PLEASE CONTINUE ON 2
nd
Page
Total Household
Size
TELL US ABOUT YOUR MATE’S ACTIVITY
Email address
Home Phone No.
Sex (M, F)
Received Weekly, Bi-Weekly, Twice
Monthly, Annually?
Name of Child Provider’s Name, Address
and Telephone Number
Weekly Fee
LIST ALL OF YOUR SOURCES OF INCOME (Income Means Money Made/ Received)
Name of Employer(s)
Gross Income Amount
Received Before Taxes
Received Weekly, Bi-Weekly, Twice
Monthly, Monthly, Annually?
Child Support
Name the Absent Parent(s)
Amount of
Child Support
Received Weekly, Bi-Weekly,
Twice Monthly, Monthly?
LIST ALL OF YOUR MATE’S SOURCES OF INCOME (Income Means Money Made /Received)
Name of Employer(s)
Other Income Source (money
coming into your household)
Received Weekly, Bi-Weekly, Twice
Monthly, Annually?
Amount
Gross Income Amount
Received Before Taxes
Other Income Source (money coming
into your household, ie interest, property)
Amount
Received Weekly, Bi-Weekly, Twice
Monthly, Monthly, Annually?
TELL US ABOUT YOUR CHILDREN’S CHILD CARE PROVIDER
Licensed?
Yes or No
Start
Date
The information I have provided on this application, and all information submitted
in support of this application is true, correct and complete. I understand that I can be
determined ineligible for day care subsidy for making false or incorrect statements or failing to
report changes.
I understand that I have the right to appeal if I am not satisfied with the action
taken on my application by the Working Parents Assistance Program. My request must be filed
within ten (10) working days from the date of the notice of decision.
I hereby authorize the Working Parents Assistance Program to verify my income,
checking and savings, insurance, shelter or disability benefits, and any and all other facts
pertinent to my eligibility for child care subsidy.
I hereby give The Working Parents Assistance Program permission to give my
licensed provider information regarding the status of my application.
I hereby give The Working Parents Assistance Program permission to contact me
by telephone, text or email.
(Please check one: yes___ no____)
Applicant’s
Signature________________________________________________Date________________
Co-Applicant’s
Signature_______________________________________________Date_________________
Case Worker’s
Signature_______________________________________________Date_________________
Are you or any of your children receiving SSA Survivor’s Benefits or Social Security Benefits from a
deceased parent? ______ If yes, how much per month? $ _________
Do any of the children for whom you need care have special needs?__________ If yes, which
child?____________________________
Do you or your mate pay court ordered child support to a child outside your home? _______ If yes, how
per month? $________
Are you or your mate currently pregnant?______ If yes, due date?________________
Do you receive TCA (Temporary Cash Assistance)?_________
Are you currently receiving child care subsidy from the State’s Child Care Subsidy Program? _______
PLEASE ANSWER THE FOLLOWING QUESTIONS
PLEASE READ THE FOLLOWING, SIGN AND DATE
***RETURN BY FAX (240) 777-1342, and/or EMAIL wpa@montgomerycountymd.gov***
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APPLICATION FOR Home Phone No. Montgomery County, Maryland (Montgomery County Maryland)

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Completed 19 August 2021

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