Fillable Fairfax County Office for Children School Age Child (Fairfax County Government)

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Fairfax County Office for Children School Age Child (Fairfax County Government)

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Fairfax County Office for Children
School Age Child Care
12011 Government Center Pkwy., Suite 936, Fairfax, VA 22035
Phone: 703-449-8989 • Fax: 703-653-1304
Sliding Fee Application
PARENT/CHILD INFORMATION
Parent/Guardian 1
First Name:
Last Name:
Date of Birth:
Cell #:
Work #:
Home Address:
City:
State:
Zip Code:
Email:
Parent/Guardian 2
First Name:
Last Name:
Date of Birth:
Cell #:
Work #:
Home Address:
City:
State:
Zip Code:
Email:
Ot
her Guardian/Contributing Household Member
First Name:
Last Name
Relationship to child:
Cell #:
Work #:
Email:
Child/ren Information
First and Last Name:
First and Last Name:
First and Last Name:
First and Last Name:
Account #: (if known) __________________
HOUSEHOLD INCOME INFORMATION
Gross Per Pay Period Gross ANNUAL Total
(
Select one)
Parent/Guardian 1’s Salary: weekly bi-weekly semi-monthly monthly $ Line A $
I am currently unemployed Date of unemployment _________
Parent/Guardian 2’s Salary weekly bi-weekly semi-monthly monthly $ Line B $
I am currently unemployed Date of unemployment _________
Alimony/Child Support weekly bi-weekly semi-monthly monthly $ Line C $
Other Income (please explain): _______________________________________ Line D $
Gross Annual Household TOTAL: Line A + (plus) Line B + (plus) Line C + (plus) Line D Line E
$
I certify that the above income information is a true and accurate statement of the financial status and composition of my household. I understand
that giving inaccurate or erroneous information may result in loss of eligibility for reduced fees and/or repayment. I will notify
SACC Registration
within 10 business days of any change in the information provided.
Parent/Guardian Signature: _________________________________________ Date ___________________________
Reasonable accommodations made upon
request; call 703-449-1414 or TTY 711.
A Fairfax County, Va., Form
Updated 08/2021
SACC is available to families who reside in Fairfax County or the City of Fairfax, and serves kindergarten through sixth
grade children, as well as children and youth ages 5 - 21 participating at Key and Kilmer Centers.
SACC provides a sliding fee scale for families who are income eligible.
If your household income is less than $132,500 per year, you may be eligible for reduced child care fees.
To apply for reduced fees please:
Complete the SACC Sliding Fee Application.
Indicate any Other Income including – child support, alimony, disability, income from other household members,
unemployment benefits, SSA/SSI benefits.
Provide a copy of the most recent pay stub (within 30-60 days) for all adults in the household living together as a
family who share income and expenses (additional documentation may be required).
Return all information to the address on the form or fax to 703-653-1304.
Income Recertification - Income recertification must be submitted as changes occur throughout the year. You
must notify SACC Registration within 10 business days of any changes in income.
Military Personnel – In addition to basic pay, special allowances such as BAH, BAS, and CMA are considered
earned income.
School or Job Training - Documentation verifying enrollment is required.
Self-Employed, Disabled, No Pay Stubs – Additional documentation is required.
Unemployed – Documentation confirming unemployment is required.
Sliding Fee Information and Application
Eligibility Requirements
Fairfax County Office for Children
School Age Child Care
12011 Government Center Pkwy., Suite 936, Fairfax, VA 22035
Phone: 703-449-8989 • Fax: 703-653-1304
Income Assessment Information
Reasonable accommodations made upon
request; call 703-449-1414 or TTY 711.
A Fairfax County, Va., Form
Updated 08/2021
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Fairfax County Office for Children School Age Child (Fairfax County Government)

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Completed 11 January 2022

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