CFWB-012 (PKA CS-925)
REV. 04/18
Page 4 of 4
Authorized Days and Hours of Care: Authorized Days and Hours of Care for Second Shift/Work/Activity Schedule
(Complete only if parent provides second shift/work/activity schedule in Section 5)
Eligibility determined and approved by (print and initial): Date: / /
Length of Eligibility from / / to / / Codes: RFC: PR: FS:
1. I understand that the information contained on this form will be used to
determine my or my family’s eligibility for services/subsidy. I understand
that by signing this application form, I agree to cooperate fully with any
investigation to verify or confirm the information I have given or any other
investigation in connection with my request for child care assistance. I will
provide additional information if requested.
2. Social Security Numbers, if provided, may be used by federal, state, and
local agencies to prevent duplication of services, fraud and for federal
reporting.
3. I agree to inform the agency immediately of any change in my needs, income,
address, living arrangement, household composition or address where care is
provided, who is providing child care, provider fees and/or hours for which child
care is needed.
4. I certify that the children indicated as needing child care are United States
(U.S.) citizens, U.S. nationals, or persons with satisfactory immigration status.
I understand that this information about these children may be submitted to
the Immigration and Naturalization Service (INS) for verification of immigration
status, if applicable. I further understand that the use or disclosure of this infor-
mation about these children is restricted to persons and organizations directly
connected with the verification of immigration status and the administration
or enforcement of provisions of the Child Care Assistance Program.
5. I understand that this application is used only for the expressed purpose of
child care assistance. To obtain other assistance such as SNAP, Medicaid, Cash
Assistance, or other services, additional applications will be required. However,
this application and any information obtained as part of an investigation of this
application may be shared with any City, State or Federal agency to which you
apply or have applied for any other assistance or benefits.
6. Federal and state laws provide for penalties of fine, imprisonment or both if
you do not tell the truth when you apply for Child Care Assistance, or when
you are questioned about your eligibility, or if you cause someone else not
to tell the truth regarding your application or continuing eligibility. Penalties
also apply if you conceal or fail to disclose facts regarding your initial or
continuing eligibility for Child Care Assistance; or if you conceal or fail to
disclose facts that would affect the right of someone, for whom you have
applied, to obtain or continue to receive Child Care Assistance. If you are the
authorized representative applying on behalf of someone else, Child Care
Assistance must be used for that person and not yourself. It is unlawful to
obtain Child Care Assistance by concealing information or providing false
information.
7. I certify that my family resources do not exceed $1,000,000.00.
It is the policy and commitment of the New York City Administration for Children’s Services that it does not discriminate on the basis of race, creed, age, color, sex, religion, national origin, alienage or citizenship
status, physical or mental disability, gender, gender identity, sexual orientation, pregnancy, marital or partnership status.
You may obtain information on your rights and responsibilities at http://otda.ny.gov/programs/applications/4148A.pdf
If you do not have access to the internet, you can call NYC ACS at (212) 835-7610 to request physical copies of the following booklets.
LDSS-4148A: What You Should Know About Your Rights and Responsibilities; LDSS-4148B: What You Should Know About Social Services Programs; LDSS-4148C: What You Should Know If You Have an Emergency
Certification: I swear and/or affirm under the penalties of perjury that all of the information I have given or will give to NYC ACS relating to Child Care Assistance is correct. I have read and understand the notices
both above and attached. I understand and agree to the above-listed certifications.
Please provide the signatures of both parents/caretakers if two parent/caretaker household.
Signature Parent/Caretaker:
Signature Second Parent/Caretaker: Signature Authorized Representative:
Print Name: Date: / / Print Name: Date: / / Print Name: Date: / /
Section 8
CERTIFICATION
Section 9
OFFICE ONLY
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If you qualify for Child Care Assistance funded by the New York State Child Care Block Grant, you have the option to choose: center-based or home-based child care. If you choose a provider that is not licensed or
registered, the provider must be enrolled as a Legally-Exempt provider. Provide below the name(s) and address(es) of your choice of provider(s). You may list additional choices on an attached sheet.
Name: Program # (if applicable)
Address:
Name: Program # (if applicable)
Address:
Name: Program # (if applicable)
Address:
Section 7
PROVIDER
