Fillable ECE012 (City of New York)

Fill Online, Printable, Fillable, Blank ECE012 (City of New York) Form

Use Fill to complete blank online CITY OF NEW YORK pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

ECE012 (City of New York)

On average this form takes 147 minutes to complete

The ECE012 (City of New York) form is 18 pages long and contains:

  • 0 signatures
  • 57 check-boxes
  • 560 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of New York

BROWSE CITY OF NEW YORK FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MEMORANDUM
To: All Parents/Guardians Applying for Child Care Assistance
Re: Immigration Status
________________________________________________________
CERTAIN PROGRAMS REQUIRE PROOF THAT YOUR CHILD
NEEDING CHILD CARE IS A U.S. CITIZEN, U.S. NATIONAL OR
PERSON WITH SATISFACTORY IMMIGRATION STATUS.
YOU WILL NOT BE ASKED FOR THE IMMIGRATION STATUS FOR
YOURSELF OR ANYONE ELSE IN THE HOUSEHOLD OTHER THAN
THE CHILD(REN) IN NEED OF CHILD CARE.
If you have any questions or to obtain a list of subsidized early
care and education programs that do not require proof of a
child’s citizenship or immigration status, please call the ACS Child
and Family Well-Being Hotline at (212) 835-7610 or go to our
website at http://www1.nyc.gov/site/acs/early-
care/eligibility.page.
66 John Street/8
th
Floor
New York, New York 10038
Child.FamilyWellBeing@acs.nyc.gov
www.nyc.gov/acs
CFWB-012 (PKA CS-925)
REV. 04/18
Page 1 of 4
Last Name First Name M.I. Relationship
Date of
Birth
MM/DD/YY
Sex
Both of Child’s
Parents Reside
in the Home?
Ethnicity
Hispanic or
Latino**
Race**
(See legend
below)
Social Security
Number
(Optional)
Child with a
Disability?
Is child U.S. Citizen/
U.S. National/
or person with
satisfactory
immigration status?
1.
oM oF oYes oNo oYes oNo oYes oNo oYes oNo
2.
oM oF oYes oNo oYes oNo oYes oNo oYes oNo
3.
oM oF oYes oNo oYes oNo oYes oNo oYes oNo
4.
oM oF oYes oNo oYes oNo oYes oNo oYes oNo
5.
oM oF oYes oNo oYes oNo oYes oNo oYes oNo
6.
oM oF oYes oNo oYes oNo oYes oNo oYes oNo
7.
oM oF oYes oNo oYes oNo oYes oNo oYes oNo
8.
oM oF oYes oNo oYes oNo oYes oNo oYes oNo
Application For Child Care Assistance
Please read instructions (CFWB-012A) and review the document checklist (CFWB-012B) for assistance when completing this and for information on what documents are required.
ATTENTION: This application is used to apply only for Category 2 or 3* child care assistance (for families not in receipt of cash assistance). To apply for Cash Assistance or other benefits,
including Category 1 Child Care Assistance (for families in receipt of cash assistance), you must use the New York State Application for Certain Benefits and Services (LDSS-2921).
OFFICE USE ONLY Case #: Application Date:
Last Name (Please include any aliases or maiden names in parentheses): First Name: M.I.: Marital Status:
Home Address: Apt. #: City/Borough: State: ZIP Code:
Is this a temporary address? Yes No If yes, does family currently reside in (check one): Homeless Shelter Doubled-up with another family Hotel/Motel Car, Bus, Train Park, Campsite Other
Telephone (Work): Telephone (Home): Telephone (Cell or Other): Email:
Do you receive Cash Assistance? Yes No CA#: What is your primary language? English Spanish Other
What is your preferred language? English Spanish Other
Section 1
APPLICANT
Section 2A
CHILD(REN) NEEDING CARE
* Category 1: Families eligible for a child care guarantee – applying for or receiving
Cash Assistance (CA), or receiving Child Care Assistance in lieu of CA or
receiving transitional child care
Category 2: Families eligible when funds are available
Category 3: Families eligible when funds are available and ACS has included them
in its Child and Family Services Plan
** Providing ethnicity and race information is voluntary and will not affect your
eligibility for Child Care Assistance or the amount of assistance that you will
be given by this agency.
Racial Affiliation Codes:
AI Native American or Alaskan Native
AS Asian
BL Black or African American
HP Native Hawaiian or Pacific Islander
WH White
Please list all children in your household needing child care. (Only children needing care)
PLEASE NOTE: All sections of this form must be filled out to be considered complete
unless the section is identified as optional. If you do not complete all required
sections of this form, you may not be considered for Child Care Assistance.
PLEASE PRINT IN ALL CAPITAL LETTERS
The following applicants may be eligible for child care assistance without regard to income and do not need to complete this application:
• Foster parents who need child care assistance to allow them to work and are only applying for assistance for the foster child(ren).
• Families in receipt of protective or preventive services.
Refer to application instructions (CFWB-012A) for details
New Change/Recertification Reopen
CFWB-012 (PKA CS-925)
REV. 04/18
Page 2 of 4
Last Name
(Include any aliases or maiden names
in parentheses)
First Name M.I. Relationship
Date of
Birth
MM/DD/YY
Sex
Ethnicity
Hispanic or
Latino**
Race**
(See legend
to the right)
Social Security
Number
(Optional)
1. Self
oM oF oYes oNo
2.
oM oF oYes oNo
3.
oM oF oYes oNo
4.
oM oF oYes oNo
5.
oM oF oYes oNo
6.
oM oF oYes oNo
7.
oM oF oYes oNo
8.
oM oF oYes oNo
Section 2B
FAMILY MEMBERS
For additional family members, please attach
a separate sheet. Include information for any
spouse, parent or caretaker of the children
applying for care who lives in the home.
Racial Affiliation Codes:
AI Native American or Alaskan Native
AS Asian
BL Black or African American
HP Native Hawaiian or Pacific Islander
WH White
Please list all other members in your entire household (not listed in Section 2A) including children under age 18 who do not need child care. List yourself first, followed by everyone who lives with you.
OFFICE USE ONLY Family Size:
Applicant’s Employer Name: Tel#: Address: City/Borough: State: ZIP Code:
Employment Start Date: Does job have a rotating shift? Yes No Does job require overtime (OT)? Yes No
If applicant has a second job
Employer Name: Tel#: Address: City/Borough: State: ZIP Code:
Employment Start Date: Does job have a rotating shift? Yes No Does job require overtime (OT)? Yes No
Second parent, caretaker or stepparent in the household
Employer Name: Tel#: Address: City/Borough: State: ZIP Code:
Employment Start Date: Does job have a rotating shift? Yes No Does job require overtime (OT)? Yes No
If second parent, caretaker or stepparent in the household has a second job
Employer Name: Tel#: Address: City/Borough: State: ZIP Code:
Employment Start Date: Does job have a rotating shift? Yes No Does job require overtime (OT)? Yes No
Section 4
EMPLOYMENT
(if employment is reason for care)
Section 3
CHILD/FAMILY
NEEDS
What is your reason for requesting Child Care Assistance?
Employment Looking for Work
Vocational Training/Educational Activities
Receiving Domestic Violence Services Homelessness
Is there a non-custodial parent available to provide child care?
Yes No
Is a parent currently active duty (full-time) in the
US Military?
No Yes
Is a parent currently a member of a National Guard
or Military Reserve Unit?
No Yes
Is the applicant receiving and/or applying for child care through
a different application? If yes please indicate the agency:
Department of Education (DOE)
Human Resources Administration (HRA)
Department of Youth and Community Development (DYCD)
Department of Homeless Services (DHS)
Consortium for Worker Education (CWE)
CFWB-012 (PKA CS-925)
REV. 04/18
Page 3 of 4
Typical work/activity schedule (i.e., educational/vocational activity) Please complete the schedule below only if the parent has a second shift, job or activity
Please complete the schedule below only if the second parent, caretaker or stepparent in the
Typical work/activity schedule for second parent, caretaker or stepparent in the household household has a second shift, job or activity
Travel Time Drop off: Travel time from the child care provider to work/activity?
Check one of the following: 15 minutes 30 minutes 45 minutes 1 hour More than 1 hour. Amount of time if more than 1 hour Public Transportation? Yes No
Pick-up: Travel time from work/activity to the child care provider?
Check one of the following: 15 minutes 30 minutes 45 minutes 1 hour More than 1 hour. Amount of time if more than 1 hour Public Transportation? Yes No
Spouse/Other Parent Drop off: Travel time from the child care provider to work/activity?
Check one of the following: 15 minutes 30 minutes 45 minutes 1 hour More than 1 hour. Amount of time if more than 1 hour Public Transportation? Yes No
Pick-up: Travel time from work/activity to the child care provider?
Check one of the following: 15 minutes 30 minutes 45 minutes 1 hour More than 1 hour. Amount of time if more than 1 hour Public Transportation? Yes No
Section 5
WORK/ACTIVITY/TRAVEL
TIME SCHEDULE
Sunday
from to
Monday
from to
Tuesday
from to
Wednesday
from to
Thursday
from to
Friday
from to
Saturday
from to
Sunday
from to
Monday
from to
Tuesday
from to
Wednesday
from to
Thursday
from to
Friday
from to
Saturday
from to
Sunday
from to
Monday
from to
Tuesday
from to
Wednesday
from to
Thursday
from to
Friday
from to
Saturday
from to
Sunday
from to
Monday
from to
Tuesday
from to
Wednesday
from to
Thursday
from to
Friday
from to
Saturday
from to
Indicate if you or anyone who is applying with you receives money from the following sources. See checklist (CFWB-012B) for documentation requirements. PLEASE PRINT
Sources Yes No Gross Amount
How often? (weekly,
biweekly, monthly, etc?)
Who is the recipient? Type of Documentation Monthly Calculations
Applicant Wages/Salary, including overtime, commissions, training programs, tips
$ Self
Second parent, caretaker or stepparent in the household Wages/Salary, incl. overtime, commissions, training programs, tips
$
Net Self-Employment Income
$
Child Support Payments (received)
$
Alimony/Spousal Support (received)
$
Unemployment Insurance Benefits, Workers’ Comp
$
Social Security Benefits (including SSI)
$
Disability Benefits (NYS, VA, Private)
$
Rental/Boarder/Lodger Income (received)
$
Dividends/Interest – Stocks, Bonds, Savings
$
Retirement, Pensions/Annuities
$
Cash Assistance (CA) Grant, Safety Net Benefits
$
Other (please specify)
$
Total Income $
Section 6
INCOME INFORMATION
OFFICE USE ONLY
0.00
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
Sunday
from to
Monday
from to
Tuesday
from to
Wednesday
from to
Thursday
from to
Friday
from to
Saturday
from to
Sunday
from to
Monday
from to
Tuesday
from to
Wednesday
from to
Thursday
from to
Friday
from to
Saturday
from to
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
SAVE
PRINT
CFWB-012A Instructions
REV. 4/18
Page 1 of 5
Dear Parent(s)/Caretaker(s),
THIS APPLICATION IS USED TO APPLY ONLY FOR CHILD CARE ASSISTANCE AS A CATEGORY 2 OR 3 FAMILY
If you are applying only for category 2 or 3 Child Care Assistance (for families not in receipt of cash assistance), you can use
this shorter application. If you want to apply for other benefits such as Cash Assistance, Supplemental Nutrition Assistance
Program (Food Stamps), Home Energy Assistance, Medicaid or other services, including category 1 Child Care Assistance (for
families in receipt of cash assistance), please ask for the New York State Application for Certain Benefits and Services (LDSS-2921).
By submitting the Application for Child Care Assistance instead of the New York State Application for Certain Benefits and
Services (LDSS-2921), you are applying for Child Care Assistance only in categories 2 and 3, i.e., when funds are available. You
are not applying in category 1, guaranteed child care.
The following instructions are provided to assist you in completing your application. When completing your application,
please remember to print clearly in block capital letters (A, B, C) using blue or black ink. Alternatively, you may complete the
form electronically, save it, and print it.
This Application must include supporting documentation such as proof of income, proof of address, and proof of employment.
SEE THE ATTACHED SUBMISSION CHECKLIST (CFWB-012B) FOR ALL REQUIRED DOCUMENTS.
READ BEFORE COMPLETING APPLICATION
If you receive preventive or protective child welfare services or you are an employed foster parent you may already be
eligible for child care assistance and may not need to complete this application. Ask your case planner to make a referral for
Child Care Assistance.
If you receive cash assistance (CA), you should contact your Human Resources Administration (HRA) JOB Center for child
care assistance.
PLEASE NOTE: If any required fields are left unanswered, the entire application will be considered incomplete.
OFFICE USE ONLY
Gray shaded boxes are for office use only. Please do not write anything in these sections.
* Category 1: Families eligible for a child care guarantee – applying for or receiving Cash Assistance (CA), or receiving Child Care Assistance in
lieu of CA or receiving transitional child care
Category 2: Families eligible when funds are available
Category 3: Families eligible when funds are available and ACS has included them in its Child and Family Services Plan
Division of Child and Family Well-Being
Instructions for Completing your Application for
Category 2 or 3 Child Care Assistance*
The availability of Child Care Assistance is dependent on funding from the Child Care Block Grant.
If there is no available funding, your child(ren) may be placed on the waiting list.
CFWB-012A Instructions
REV. 4/18
Page 2 of 5
Please indicate at the top right whether you are submitting a new application, requesting a change of status/recertification,
or requesting to reopen your case.
SECTION 1 APPLICANT
The applicant is the adult parent or caretaker requesting care. Unless otherwise noted, this section must contain the following
information about the applicant only:
1. Print your Last and First Name, and middle initial. Please put any aliases or maiden names in parentheses.
2. Indicate your marital status (single, married, divorced or widowed).
3. Print your Home Address.
4. Indicate if address is temporary. Check “YES” only if the family is currently living in a homeless shelter, doubled-up with
another family, in a hotel/motel, in a car/ bus/ train, in a park/campsite, or other.
5. Print your Telephone Numbers, including area code – work, home, and cellular/other (if applicable).
6. Print your e-mail address (optional).
7. Check “YES” or “No” for Cash Assistance Status. (If you are a CA recipient, you should apply for child care through your
Human Resources (HRA) Job Center worker).
8. Check the box for the language that is spoken most often in your household. If “other,” print the name of the language.
9. Check the box for the language you prefer to communicate in. If “other,” print the name of the language.
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for New York City Residency.
SECTION 2A CHILDREN NEEDING CARE
1. Print the last and first name, and middle initial of each child in the household for which you are applying for child care assistance.
2. For each child in the household, print their relationship to you (e.g. child).
3. Print the date of birth and check the box indicating the sex for each child listed.
4. Indicate whether both of the child’s parents live in the home.
5. Check “YES”or “NO” to indicate if each child applying is Hispanic or Latino or not. Providing ethnicity information is voluntary
and will not affect your eligibility for Child Care Assistance or the amount of assistance that you will be given by this agency.
6. Fill in the Race column for each child in need of child care.You may choose multiple race categories for a single child.
Providing race information is voluntary and will not affect your eligibility for Child Care Assistance or the amount of
assistance that you will be given by this agency.Please use the codes below.
AI - Native American or Alaskan Native AS - Asian BL - Black or African American
HP - Native Hawaiian or Pacific Islander WH - White
7. Provide each child’s Social Security Number (SSN). You are not required to provide SSNs. They may be used by federal,
state, and local agencies to prevent duplication of services and fraud, and for Federal Reporting.
8. Check “YES” or “NO” to indicate whether the child needing child care has a disability
1
. If your child is determined eligible for
child care assistance, please go to http://www1.nyc.gov/site/acs/early-care/forms.page to obtain a Special Needs Application.
9. Check”YES”or”NO”to indicate whether the child needing child care is a U.S. citizen, U.S. national or person with satisfactory
immigration status.
10. Attach a separate sheet for additional children (if you are requesting care for more than eight (8) children).
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for citizenship/immigration status only for
the child(ren) needing child care.
1
A child with a disability or special needs is a child incapable of caring for himself or herself and who has been diagnosed as having one or more of the follow-
ing conditions to such a degree that it adversely affects the child’s ability to function normally: visual impairment, deafness or other hearing impairment, ortho-
pedic impairment, emotional disturbance, mental retardation, learning disability, speech impairment, health impairment, autism or multiple handicaps. Any
such diagnosis must be made by a physician, licensed or certified psychologist or other professional with the appropriate credentials to make such a diagnosis.
CFWB-012A Instructions
REV. 4/18
Page 3 of 5
SECTION 2B FAMILY MEMBERS
1. A family member is any other member in your entire household, including children who do not need child care. List yourself
first, followed by everyone else who lives with you including child’s second parent, caretaker and stepparent if applicable.
Caretaker includes legal guardian, caretaker relative or any other person in loco parentis to the child. Print last and first
name, and middle initial if applicable.
2. Print each person’s relationship to you (e.g. spouse, partner, grandparent, parent, etc.).
3. Print the date of birth and and check the box indicating the sex for each person in the household.
4. Check “YES” or “NO” to indicate if each member in the household is Hispanic or Latino or not. Providing ethnicity
information is voluntary and will not affect your eligibility for Child Care Assistance or the amount of assistance that you will
be given by this agency.
5. Fill in the Race column for everyone who lives with you. You may choose multiple race categories for a single person.
Providing race information is voluntary and will not affect your eligibility for Child Care Assistance or the amount of
assistance that you will be given by this agency. Please use the codes below.
AI - Native American or Alaskan Native AS - Asian BL - Black or African American
HP - Native Hawaiian or Pacific Islander WH - White
6. Fill in the Social Security Number (SSN) for your family members. SSN is optional. SSN may be used by federal, state, and
local agencies to prevent duplication of services and fraud, and for Federal Reporting.
7. If there are more than eight (8) household members, attach a separate sheet to list all their information.
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for all children in the household under age 18,
regardless if child care is needed for the child, to verify the child’s relationship to the parent/applicant and to verify the
child’s age.
SECTION 3 CHILD/FAMILY NEEDS
1. Please check the appropriate box(es) to indicate your reason(s) for requesting child care assistance.
• Employment
• Vocational training, or educational activities
• Receiving Domestic Violence Services
• Looking for Work
• Homelessness
2. Check “YES” or “NO” to indicate whether there is a non-custodial parent available to provide child care.
3. Check the appropriate box to indicate whether a parent is currently active full-time in the U.S. Military. You must check
”YES” or “NO” for the application to be complete.
4. Check the appropriate box to indicate whether a parent is currently a member of a National Guard or Military Reserve Unit.
You must check”YES” or “NO” for the application to be complete.
5. Indicate whether the applicant is receiving and/or applying for child care through a different agency and select the agency.
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for each reason for care. Documentation of
military status is not required. An applicant must provide documentation of income received from their military duty.
CFWB-012A Instructions
REV. 4/18
Page 4 of 5
SECTION 4 EMPLOYMENT
(Complete for each employed parent, caretaker or stepparent in the household if your reason for requesting child care
assistance is employment or you are reporting income from employment)
1. Print the applicant’s employer name, address, and telephone number.
2. Print the employment start date.
3. Check the appropriate box to indicate whether your job has a rotating shift and/or requires overtime.
4. If applicable, print the employer name, address and telephone number for second parent, caretaker or stepparent in the
household.
5. If applicable, print the employment date of second parent, caretaker or stepparent in the household.
6. If applicable, check the appropriate box to indicate whether the second parent, caretaker or stepparent in the household has a
rotating shift and/or requires overtime.
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for employment.
SECTION 5 WORK/ACTIVITY/TRAVEL TIME SCHEDULE
(Complete for each parent, caretaker or stepparent in the household who is employed or has an educational/vocational activity)
1. Print the typical scheduled work or activity hours for each day of the week. Indicate if hours are AM or PM.
2. If there is a second shift, job, or activity, print the schedule for that activity.
3. If applicable, print the typical scheduled work hours for each day of the week for the second parent, caretaker or stepparent
in the household.
4. If the second parent, caretaker, or stepparent in the household has a second shift, job, or activity, print the schedule for
that activity.
5. Check the time it takes for the applicant to travel to and from work/activity to provider.
6. Indicate if the applicant uses public transportation to travel to and from work/activity to provider.
7. If applicable, check the time it takes for the second parent, caretaker, or stepparent in the household to travel to and from
work/activity to provider.
8. Indicate if the second parent, caretaker or stepparent in the household uses public transportation to travel to and from
work/activity to provider.
SECTION 6 INCOME INFORMATION
For this section, answer only items for which you or a household member has earned income. Please include income/benefits
information for yourself and any other adult household members including your spouse who lives with you,or an adult who
lives with you and with whom you have a least one child in common. Also include any person under the age of 18 who is
legally responsible for the child or children for whom child care assistance is sought.
1. Check (✓) Yes or No for yourself and anyone who lives with you for each kind of income.
2. For each “Yes” answer, PRINT the dollar ($) amount or value, how often it is received, and the name of the person who gets
the income.
3. All income must be reported on the application.
4. If you indicate receipt of cash assistance, you should apply for child care through your HRA Job Center worker.
5. If you are unsure where to list a type of income, you may include it under “other”.
DOCUMENTATION: See checklist (CFWB-12B) for documentation required for income.
CFWB-012A Instructions
REV. 4/18
Page 5 of 5
SECTION 7 PROVIDER
1. 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.
2. If you know the provider/program where you would like to enroll your child please indicate the name, address, and ACS
program number (if applicable).
SECTION 8 CERTIFICATION
Please read the certification section carefully and sign. If the applicant is completing the application for someone else, they
must sign their own name. If two-parent household, both parents must sign the application.
By signing, you certify that your combined family resources do not exceed $1,000,000. Examples of family resources are: cash,
savings and checking accounts, your home, real estate, cars, stocks, bonds, mutual funds, IRAs, 401(k), annuity, trust fund, life
insurance, safe deposit box contents, etc.
SECTION 9 FOR OFFICE USE ONLY
Do not complete this section. Staff who are determining your family’s eligibility for care will use this.
VOTER REGISTRATION INFORMATION
The last page of the Application for Child Care Subsidy is an application to register to vote. If you would like help filling out the
voter registration application form, call 311. Applying to register or declining to register to vote will not affect your eligibility
for child care assistance or the amount of assistance that you will be given by this agency.
RIGHTS AND RESPONSIBILITIES INFORMATION
You may obtain information about 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
booklets which highlight your Rights and Responsibilities be mailed to you.
• 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
CFWB-012B
REV. 3/18
Page 1 of 2
The Application for Child Care Assistance (CFWB-012) must include supporting documentation.
Check to ensure that documentation is provided for each requirement of subsidy eligibility.
1 APPLICATION CFWB012
Ensure all sections are completed, including:
If two-parent household, both parents signed Military status (Section 3) Travel time (Section 5)
2 NEW YORK CITY RESIDENCY
Copy of one of the following:
IDNYC Utility Bill Section 8 Award Letter
Driver’s License Rent Receipt NYCHA Certificate
Other
PLEASE NOTE: If “OTHER” documentation is not satisfactory, ACS will notify applicant.
3 ONLY FOR CHILD(REN) NEEDING CHILD CARE: CITIZENSHIP/IMMIGRATION STATUS
Copy of one of the following:
US Birth Certificate Alien Registration Card including Permanent Resident or Green Card
US Passport Form FS-240 (Report of Birth Abroad of a U.S. Citizen)
Naturalization Certificate Other
PLEASE NOTE: If “OTHER” documentation is not satisfactory, ACS will notify applicant.
4 CHILD’S RELATIONSHIP TO PARENT/APPLICANT
Copy of one of the following for all children in the household under age 18, regardless if child care is needed for the child:
Birth Certificate Adoption record
Baptismal record Court order for legal guardian with financial responsibility
Passport with parent signature
5 AGE
Copy of one of the following for all children in the household under age 18, regardless if child care is needed for the child:
Birth Certificate Adoption record
Baptismal record Alien Registration Card
Passport
6 INCOME
All Applicants submitting CFWB-012 must provide documentation of income regardless of reason for care.
If Employed:
CFWB-015 - Referral to Employer for Employee Income Information
OR
Pay Stubs (Bi-weekly = Every 2 weeks; Semi-monthly = Twice a month)
Weekly – 4 current, consecutive pay stubs if gross amount is the same
Weekly – 12 current, consecutive pay stubs if gross varies
Bi-weekly/Semi-monthly – 2 current, consecutive pay stubs if gross amount is the same
Bi-weekly/Semi-monthly – 6 current, consecutive pay stub if gross varies
Child Care Assistance New Application Submission Checklist
Please go to http://www1.nyc.gov/site/acs/early-care/forms.page for forms and application instructions.
For more information call 311 or 212-835-7610.
CFWB-012B
REV. 3/18
Page 2 of 2
If Self-Employed:
If self-employed 1 year or more: current, complete and signed income tax package (ex. 1040, 1065, Schedule C, SE for
partnership, K-1, etc.)
If self-employed less than 1 year, complete and submit CFWB-031 Self-Employment Income Information Attestation
Other Income:
Recent checks, pay stubs or current award letters required for other income identified by the applicant on the CFWB-012
including SSI, SSD, unemployment benefits, rental income, pensions, annuities, worker’s compensation, alimony, and child
support.
7 REASONS FOR CARE
Applicant must document one of the following reasons for care:
a) Working minimum of 20 hours or more per week:
See above under income for required documents regarding Employment and / or Self-employment.
b) Educational/Vocational activity:
2 Year College/Vocational School (One of the following)
CFWB-005 with School’s stamp
A letter from the training institution on official letterhead is also acceptable, but must contain all necessary information
reflected on the CFWB-005.
4 Year full time college student plus work
CFWB-015 OR Pay Stubs indicating work 17 ½ hours per week
And one of the following
CFWB-005 with school’s stamp
A letter from the training institution on official letterhead is also acceptable, but must contain all necessary information
reflected on the CFWB-005.
c) Looking for Work (One of the following):
CFWB-026 - Work Search Record
Approved Work Search Plan from the NYS Dept. of Labor
Proof of receipt of Unemployment Insurance
d) Homeless (One of the following):
Written Referral from Hotel/Shelter
CFWB-027 Housing Questionnaire/Attestation
e) Domestic Violence Referral (From Domestic Violence service provider):
Referral for services in response to domestic violence
Please go to http://www1.nyc.gov/site/acs/early-care/forms.page for forms and application instructions.
For more information call 311 or 212-835-7610.
SAVE
PRINT
New York State Voter Registration Form
Register to vote
With this form, you register to vote in elections in
New York State. You can also use this form to:
•
change the name or address
on your voter registration
•
become a member of a political party
• change your party membership
To register you must:
• be a US citizen;
•
be 18 years old by the end of this year;
•
not be in prison or on parole
for a felony conviction;
• not claim the right to vote elsewhere.
Send or deliver this form
Fill out the form below and send it to your
county’s address on the back of this form,
or take this form to the office of your County
Board of Elections.
Mail or deliver this form at least 25 days before
the election you want to vote in. Your county will
notify you that you are registered to vote.
Questions?
Call your County Board of Elections
listed on the back of this form or
1-800-FOR-VOTE (TDD/TTY Dial 711)
Find answers or tools on our website
www.elections.ny.gov
Verifying your identity
We’ll try to check your identity before Election
Day, through the DMV number (driver’s license
number or non-driver ID number), or the last
four digits of your social security number,
which you’ll fill in below.
If you do not have a DMV or social security
number, you may use a valid photo ID, a current
utility bill, bank statement, paycheck, government
check or some other government document that
shows your name and address. You may include a
copy of one of those types of ID with this form—
be sure to tape the sides of the form closed.
If we are unable to verify your identity before
Election Day, you will be asked for ID when
you vote for the rst time.
Last name
First name
16
Apt. Number
I need to apply for an Absentee ballot.
I would like to be an Election Day worker.
Middle Initial
Sufx
City/Town/Village
Zip code
Zip code
Af davit: I swear or afrm that
• I am a citizen of the United States.
• I will have lived in the county, city or village
for at least 30 days before the election.
• I meet all requirements to register
to vote in New York State.
• This is my signature or mark in the box below.
• The above information is true, I understand that
if it is not true, I can be convicted and fined up
to $5,000 and/or jailed for up to four years.
I do not have a New York State driver’s license or a Social Security number.
xxx–xx–
Last four digits of your Social Security number
Democratic party
Republican party
Conservative party
Green party
Working Families party
Independence party
Women’s Equality party
Reform party
Other
Address (not P.O. box)
Your address was
Your previous state or New York State County was
Your name was
New York State County
3
Have you voted before? Yes No
8
14
15
Your name
More information
Items 5, 6 & 7 are optional
The address
where you live
The address where
you receive mail
Skip if same as above
Voting history
Voting information
that has changed
Skip if this has not changed
or you have not voted before
Identication
You must make 1 selection
For questions, please refer to
Verifying your identity above.
Political party
You must make 1 selection
Political party enrollment is
optional but that, in order to
vote in a primary election of
a political party, a voter must
enroll in that political party,
unless state party rules allow
otherwise.
Optional questions
Qualications
10
What year?
11
12
Address or P.O. box
P.O. Box
City/Town/Village
9
13
Birth date
Y Y Y YD DM M
/ /
4
6
Phone
– –
Sex M F
5
Sign
Date
Are you a citizen of the U.S.? Yes No
If you answer No, you cannot register to vote.
1
If you answer No, you cannot register to vote unless you will be 18 by the end of the year.
Will you be 18 years of age or
older on or before election day?
Yes No
2
New York State DMV number
Rev. 07/2016
It is a crime to procure a false registration or to furnish false information to the Board of Elections.
Please print in blue or black ink.
For board use only
中文資料:若您有興趣索取中文資料表格,
請電: 1-800-367-8683

1-800-367-8683
Información en español: si le interesa obtener este
formulario en español, llame al 1-800-367-8683
한국어: 한국어 양식을 원하시면
1-800-367-8683 으로 전화 하십시오.
Email
7
I wish to enroll in a political party
I do not wish to enroll in a political party
No party
Board of Elections Borough Ofces
General Ofce
32 Broadway, 7 Fl
New York, NY 10004-1609
Tel: 1.212.487.5300 / 1.212.487.5400
Phone Bank: 1.866.VOTE.NYC
E-mail: electioninfo@boe.nyc.ny.us
Web Page: www.vote.nyc.ny.us
Staten Island
1 Edgewater Plaza, 4 Fl
Staten Island, NY 10305
Tel: 1.718.876.0079
Manhattan
200 Varick Street, 10 Fl
New York, NY 10014
Tel: 1.212.886.2100
Bronx
1780 Grand Concourse, 5 Fl
Bronx, NY 10457
Tel: 1.718.299.9017
Brooklyn
345 Adams Street, 4 Fl
Brooklyn, NY 11201
Tel: 1.718.797.8800
Queens
118-35 Queens Boulevard, 11th Fl
Forest Hills, NY 11375
Tel: 1.718.730.6730
Borough Ofces
Rev. English 4/15, 10/15
Eye color
If you would like to be an organ and tissue donor, you may enroll in
the NYS Department of Health (DOH) Donate Life™ Registry online
at www.nyhealth.gov or provide your name and address below.
You will receive a confirmation letter from DOH, which will also
provide you an opportunity to limit your donation.
By signing below,
you certify that you are:
• 18 years of age or older;
• consenting to donate all of your organs and
tissues for transplantation, research, or both;
• authorizing the Board of Elections to provide
your name and identifying information to
DOH for enrollment in the Registry;
• and authorizing DOH to allow access to this in-
formation to federally regulated organ procure -
ment organizations and NYS-licensed tissue
and eye banks and hospitals upon your death.
(Optional) Register to donate your organs and tissues
Last name
First name
Address
Apt. Number
Sex M F
City
Height
Ft.
In.
Sign Date
Sufx
Apt. Number
Middle Initial
Zip code
Birth date
YYYYDD
//
MM
Enfocus Software - Customer Support
BOARD OF ELECTIONS
32 BROADWAY 7 FL
NEW YORK NY 10275-0067
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
BUSINESS REPLY MAIL
YN KROY WENL I AM SSA LC - TSR I F PERMIT NO. 4339
POSTAGE WILL BE PAID BY ADDRESSEE
Board of Elections Borough Ofces
General Ofce
32 Broadway, 7 Fl
New York, NY 10004-1609
Tel: 1.212.487.5300 / 1.212.487.5400
Phone Bank: 1.866.VOTE.NYC
E-mail: electioninfo@boe.nyc.ny.us
Web Page: www.vote.nyc.ny.us
Staten Island
1 Edgewater Plaza, 4 Fl
Staten Island, NY 10305
Tel: 1.718.876.0079
Manhattan
200 Varick Street, 10 Fl
New York, NY 10014
Tel: 1.212.886.2100
Bronx
1780 Grand Concourse, 5 Fl
Bronx, NY 10457
Tel: 1.718.299.9017
Brooklyn
345 Adams Street, 4 Fl
Brooklyn, NY 11201
Tel: 1.718.797.8800
Queens
118-35 Queens Boulevard, 11th Fl
Forest Hills, NY 11375
Tel: 1.718.730.6730
Borough Ofces
Rev. English 4/15, 10/15
Eye color
If you would like to be an organ and tissue donor, you may enroll in
the NYS Department of Health (DOH) Donate Life™ Registry online
at www.nyhealth.gov or provide your name and address below.
You will receive a confirmation letter from DOH, which will also
provide you an opportunity to limit your donation.
By signing below,
you certify that you are:
• 18 years of age or older;
• consenting to donate all of your organs and
tissues for transplantation, research, or both;
• authorizing the Board of Elections to provide
your name and identifying information to
DOH for enrollment in the Registry;
• and authorizing DOH to allow access to this in-
formation to federally regulated organ procure -
ment organizations and NYS-licensed tissue
and eye banks and hospitals upon your death.
(Optional) Register to donate your organs and tissues
Last name
First name
Address
Apt. Number
Sex M F
City
Height
Ft. In.
Sign Date
Sufx
Apt. Number
Middle Initial
Zip code
Birth date
YYYYDD
//
MM
Enfocus Software - Customer Support
BOARD OF ELECTIONS
32 BROADWAY 7 FL
NEW YORK NY 10275-0067
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
BUSINESS REPLY MAIL
YNKROY WENL I AM SSA LC - TSR I F PERMIT NO. 4339
POSTAGE WILL BE PAID BY ADDRESSEE
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

ECE012 (City of New York)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document