CC-192 (Rev 12/17)
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF FAMILY DEVELOPMENT
NJ CHILD CARE SUBSIDY PROGRAM
Application Addendum
All families receiving a subsidy through the NJ Child Care Subsidy Program must provide the following information:
Are your family assets worth more than $1,000,000? No Yes
Note: Assets may include but are not limited to, personal bank accounts, business accounts, real estate, and personal property.
If the primary language spoken in your home is not English, please specify that language:
Is the Applicant:
On Full-Time Active Military Duty No Yes
In the National Guard/Military Reserve No Yes
Self-Employed No Yes
Is there a Co-Applicant? No Yes
If yes, are they:
On Full-Time Active Military Duty No Yes
In the National Guard/Military Reserve No Yes
Self-Employed No Yes
Are you homeless based on one or more of the following?
No Yes
Living in an emergency or transitional shelter.
Staying in a motel, hotel, trailer park, or campground or sharing housing with other persons due to loss of housing,
economic hardship, or similar reason.
Living in a car, bus/train station, park, abandoned building.
Living or sleeping in any public or private place that is not normally used as a residence or as a regular sleeping
accommodation.
Living in substandard housing (i.e. no electricity, running water, etc.).
I hereby certify that all of the information provided is true and correct to the best of my knowledge. I also acknowledge that
submitting false or misleading information, intentionally omitting information or intentionally causing others to omit or fail to
report information is cause for denial or termination from the child care program and I may be subject to all legal and
equitable remedies.
Applicant Name Applicant Signature Date
Co-Applicant Name Co-Applicant Signature Date
DISCRIMINATION
This program prohibits discrimination in determining eligibility for child care assistance.
If you believe you have been discriminated against by the New Jersey Child Care Subsidy Program because of race, color, disability, religion, national origin or another reason, you can contact:
Office of the Director, Division of Family Development, N.J. Department of Human Services, P.O. Box 716, Trenton, New Jersey 08625
