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Quality First Scholarships Program

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Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 1 of 10
Quality First Scholarships Program
Family Application for Fiscal Year 2021 (July 1, 2020 - June 30, 2021)
Scholarships are awarded to child care sites participating in the Quality First (QF) Scholarships Program to
distribute to eligible families based on family eligibility criteria formed by First Things First. To receive a
scholarship, families must complete this application, attach the required documentation, and provide it to a QF
site currently participating in the Scholarships Program. The scholarship may not cover all charges; review co-pay
amounts with your participating QF site before enrollment (if applicable). To clarify your situation contact:
regionalscholarships@vsuw.org or call 1-866-973-0012.
Only two (2) scholarships are permitted per family household (one scholarship per child)
Applying Child(ren) 0-5
Name(s):
First
Last
Date of Birth
(mm/dd/yyyy)
Documented
Special Need
☐IEP ☐IFSP ☐504 Plan
☐IEP ☐IFSP ☐504 Plan
Parent/Guardian
Name(s):
First
Last
Relationship to Applying Child(ren)
Additional Household
Member Name(s):
First
Last
Relationship to Applying Child(ren)
Street Address (child must be an AZ resident)
City
Mailing Address (if different from above)
City
Email Address
Phone Number Cell Y/N
2020 Federal Poverty Levels (FPL)
supplied by the U.S. Department of Health and Human Services
Family
Size
2
3
4
5
6
7
8*
200%
of FPL
$34,480
$43,440
$52,400
$61,360
$70,320
$79,280
$88,240
*For each person over family size of eight (8) add $8,960
Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 2 of 10
REQUIRED: Statement of Lawful Presence & Eligibility to Receive Public Benefits
☐ REQUIRED: Child(ren) receiving a scholarship must be a U.S. citizen or national or an eligible alien. The
Statement of Lawful Presence & Eligibility to Receive Public Benefits form must be completed for each child
applying for Quality First Scholarships. In addition to the completed form, one of the documents listed on page 10
must be provided as verification of lawful presence and eligibility.
*Scholarships are reserved for children age 0-5, not yet eligible for Kindergarten. Children with a date of birth of
8/31/2015 or earlier are considered Kindergarten eligible as of 9/1/2020, and may not receive a scholarship
after this date.
REQUIRED: Household size must be defined by Option 1 or Option 2.
☐ Option 1: Public Assistance (Determines household size AND family income)
Attach your public assistance approval letter dated within the last twelve (12) months; letters should include the
applying child(ren)’s name(s) and monthly gross income and household size. (Food Stamps, AHCCCS, and/or Cash
Assistance/TANF)
According to your public assistance letter:
____________Number of parents/guardians/contributing members in the family household
____________Number of children in the family household
____________Family Gross Annual Income
Families receiving AHCCCS may access a copy of their public assistance approval letter at:
www.healthearizonaplus.gov
You may stop here and proceed to the Parent Declarations section of this application on pg. 5.
No additional information is needed.
☐ Option 2: Tax Records (Determines household size, does NOT determine family income)
Provide a copy of your family's most current annual income tax return (pg.1 of 1040 tax form) with listed
dependents. Returns should be for the 2019 tax year or later and applying child(ren)'s names should be included.
☐ I have provided a tax return (2019 tax year or later)
☐ I have provided a tax return, but my tax records do not include the applying child or otherwise do not
accurately reflect my situation (to amend household size you must submit additional documentation)*
☐ Birth certificates for siblings adopted or born after tax year (income for both parents listed on
birth certificate will be required unless a superseding custody agreement exists)
☐ Custody agreement
☐ Marriage certificate
☐ Divorce decree
☐ Foster care or adoption documentation
☐ Other (only accepted with prior approval from VSUW and FTF)
*Your participant will use QF guidelines to make a final determination of household size and countable income.
Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 3 of 10
Earned Income Documentation Requirements for Applicants Qualifying Using Option 2
Income information is necessary to process your application, please provide ONE of the following as they apply for each
contributing member.
Contributing Member(s): Any household member related by birth, marriage, or adoption; contributing member will also
include anyone who claims the child as a dependent on his/her taxes or public assistance letter.
☐ Employed by Other (must provide documentation of one of the following options):
☐ One month of current consecutive pay stubs
Participants calculate Gross Annual Income (BEFORE taxes) using pay stubs. Do not submit W-2 forms.
Monthly = 12 pay periods - 1 pay stub
Twice per month = 24 pay periods - 2 pay stubs
Biweekly = 26 pay periods - 2 pay stubs
Weekly = 52 pay periods - 4 pay stubs
Pay Descriptions that count towards gross annual income: regular/straight pay, paid time off, vacation, holiday,
sick time, shift differentials, bereavement, tips and commission, housing and subsistence allowances.
NOTE:
Overtime, bonuses, and per diem do NOT count towards gross annual income.
OR
☐ Written statement from employer, on company letterhead, that includes a gross annual income OR hourly rate
with average hours worked and frequency of pay
☐ Self-Employed (must provide documentation of one of the following options):
☐ Tax Form 1040 with applicable forms such as schedules C, C-EZ, E, F and K1 AND monthly ledgers verifying
gross income, receipts for business income and expenses for the three most recent months
OR
☐ Signed profit and loss statement for the three most recent months AND monthly ledgers verifying gross
income, receipts for business income and expenses for the three most recent months
* If the business has a requirement to file taxes, but has not done so, you must provide a valid extension from
the IRS
☐ Unemployed (must provide the following. See pg. 4 for additional unearned income requirements):
☐ No Income Declaration Form (mandatory for all contributing members w/no earned income)
☐ Homeless (must provide documentation of one of the following options):
☐ Signed statement from your case manager
OR
☐ Signed personal statement explaining circumstances (only accepted with prior approval from VSUW and FTF)
Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 4 of 10
Unearned Income Documentation Requirements for Applicants Qualifying Using Option 2
☐ My household does NOT receive any unearned income
☐ My household DOES receive unearned income (documentation of this income, amount and frequency, is required and
counted in the eligibility determination):
☐ Education assistance (not loans)
☐ Foster care or adoption payments
☐ Government or tribal income (per cap, TANF)
☐ Social Security income (disability, survivor benefits, etc.)
☐ Retirement payments
☐ Veteran benefits
☐ Unemployment insurance statement
☐ Child support or spousal maintenance
☐ Custody A - both parents’ total income is needed if child lives in both homes and both are responsible
for child care costs
OR
☐ Custody B – other parent’s income not counted if primary or applying parent receives child/spousal
support (applying parent must provide documentation of support amount and frequency)
Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 5 of 10
Parent Declarations
Initial each of the following boxes to certify that you have read and understand the guidelines for a Quality First
Scholarship.
I understand that there are additional requirements to meet in order to qualify for a Navajo
Nation, Arizona Off-Reservation Scholarship. I am attaching the supporting documents.
(This declaration does not apply to Quality First Scholarship applicants.)
I have reviewed the eligibility requirements and have attached supporting documentation for
ALL income sources from ALL contributing members in my household.
I understand that the participant may charge a monthly co-pay that will be my responsibility.
I understand that First Things First pays the participant for my child’s Quality First Scholarship.
I understand that upon enrollment, I will receive a Family Award Notification Letter that lists
my child’s scholarship award (part time or full time) and the monthly reimbursement amount
the participant receives for that scholarship.
I understand that this scholarship cannot be guaranteed to continue beyond June 30, 2021.
I understand that a single family may receive a maximum of two (2) full time scholarships,
with a maximum of one (1) full time scholarship per child.
I understand that foster children, placed by the state of Arizona, are not eligible for Quality
First Scholarships as they should be able to access DES child care subsidy or Head Start via
their caseworker.
I understand that I must accept the DES child care subsidy if/when it is offered. Declining the
subsidy will result in the loss of any Quality First Scholarships
I understand that scholarship eligibility is determined once per fiscal year.
I understand that if my child no longer attends the program, I cannot transfer my scholarship
to another site. If pursuing a scholarship at another Quality First program, I must reapply at
the desired location and be awarded a scholarship at that site.
I understand that in order for my child to be eligible for a part time scholarship, he or she
must be scheduled to attend at least 8 days and 34 hours per month, and that to be eligible
for a full time scholarship, he or she must be scheduled to attend at least 8 days and 93 hours
per month.
I agree to bring my child 85% of his or her scheduled time in order to fulfill the purpose of the
scholarship which is to give my child early learning opportunities. I understand that excessive
absences may result in the loss of the scholarship.
I understand that if any questions are left blank or if any attachments are missing, my
application will be returned as incomplete. This may cause a delay in approval.
I understand that inquiries about my child’s scholarship may be made to Valley of the Sun
United Way at 602.240.6324 or 1.866.973.0012
Declarative Statement:
I understand that personal information contained on this application will be reported to First Things First, reviewed in
audits, shared with other state agencies for program compliance and used publicly in aggregate, both regionally and
statewide. I also understand that scholarship funding is temporary in nature and that I may be liable for any dollars
received based on false information. Completion of this application does not guarantee a scholarship.
______________________________ _________________________________ _______________
Printed Name of Parent/Guardian Signature Date
Please make a copy of this page for Parent/Guardian records
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signature
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Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 6 of 10
Participant Verification & Determination of Eligibility
Must be completed and initialed by site administrator on or before enrollment date
All pages in application have been filled out completely.
Child's age and legal residency have been verified. (Ages 0-5, not yet eligible for Kindergarten.)
Family has been informed of co-payment (if applicable) not covered by the Scholarships Program.
Family has signed and received a copy of the Family Award Notification Letter with their child’s scholarship
award (full time or part time) and monthly reimbursement amount listed.
Eligibility has been determined; income and household verification supporting documents are attached.
2020 Federal Poverty Levels (FPL)
CIRCLE YOUR FINAL HOUSEHOLD SIZE DETERMINATION & ADD FINAL GROSS INCOME IN APPROPRIATE BOX
Family Size =
2
3
4
5
6
7
8*
GAI =
200% of FPL
$34,480
$43,440
$52,400
$61,360
$70,320
$79,280
$88,240
*For each person over family size of eight (8) add $8,960
_____________________________ ________________________________ _______________
Printed Name of Staff Member Signature Date
click to sign
signature
click to edit
Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 7 of 10
STATEMENT OF LAWFUL PRESENCE & ELIGIBILITY
TO RECEIVE PUBLIC BENEFITS
QUALITY FIRST SCHOLARSHIPS
Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the “Act”), 8 U.S.C.
§§ 1611 & 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen
nationals, “qualified aliens” (and sometimes only particular categories of qualified aliens), nonimmigrants, and
certain aliens paroled into the United States are eligible to receive public benefits. Public benefits under the Act
include grants and contracts as well as payments or assistance to an individual, household or family unit for welfare,
health, disability, postsecondary education and other similar benefits. Individuals who apply for a public benefit must
make a written declaration under penalty of perjury that they are eligible to receive public benefits and submit
documentation establishing that eligibility.
Arizona Revised Statutes §§ 1-501 & 1-502 require, in general, that a natural person applying for a public benefit
must submit certain documentation that satisfactorily demonstrates that the applicant is lawfully present in the
United States and make a declaration under penalty of perjury that the submitted documentation of lawful presence
is true.
Directions: All applicants who are natural persons (i.e., individuals) must complete Sections I, II, and IV. Applicants
who are natural persons and are not U.S. citizens or nationals must also complete Section III. Submit this
completed form and a copy (front and back, if any) of one or more documents from the attached list that
demonstrate eligibility and lawful presence in the United States.
SECTION I — CHILD INFORMATION
PRINT OR TYPE CHILD’S NAME _______________________________________________________
GRANT OR OTHER BENEFIT APPLYING FOR
Quality First Scholarships
SECTION II — CITIZENSHIP OR NATIONAL STATUS DECLARATION
Is the child a citizen or national of the United States? (check one) ___ Yes ___ No
If the answer is “Yes,” where was the child born? List city, state (or equivalent), and country.
City __________________ State (or equivalent) _________________ Country or Territory ______________
If the child is a citizen or national of the United States, go to Section IV. If he/she is not
a citizen or national of the
United States, please complete Sections III and IV.
Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 8 of 10
SECTION III — ALIEN STATUS DECLARATION
Directions: To be completed by parent/guardian of applicants (child) who are not citizens or nationals of the United
States. Please indicate alien status by checking the appropriate box.
“Qualified Alien” Status (8 U.S.C. §§ 1611(a), 1621(a)(1), 1641(b) and (c))
□ 1. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA).
□ 2. An alien who is granted asylum under Section 208 of the INA.
□ 3. A refugee admitted to the United States under Section 207 of the INA.
□ 4. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA.
□ 5. An alien whose deportation is being withheld under Section 243(h) or 241(b)(3) of the INA.
□ 6. An alien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.
□ 7. An alien who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education
Assistance Act of 1980).
□ 8. An alien who is, or whose child or child’s parent is a “battered alien” or an alien subjected to extreme
cruelty in the United States and who qualifies under 8 U.S.C. § 1641(c)(1)(B).
□ 9. An alien who has been granted nonimmigrant status under Section 101(a)(15)(T) of the INA (human
trafficking) or who has a pending application that sets forth a prima facie case for eligibility for such
nonimmigrant status.
□ 10. An alien from Iraq or Afghanistan granted special immigrant status under Section 101(a)(27) of the INA.
See 8 U.S.C. §§ 1101 (Afghanistan) & 1157 (Iraq) (resettlement support).
Nonimmigrant Status (8 U.S.C. § 1621(a)(2))
□ 11. A nonimmigrant under the Immigration and Nationality Act (8 U.S.C. § 1101 et seq.). Nonimmigrants are
persons who have temporary status for a specific purpose. See 8 U.S.C. § 1101(a)(15). (Applicable to state
public benefits only.)
Alien Paroled into the United States For Less Than One Year (8 U.S.C. § 1621(a)(3))
□ 12. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA.
(Applicable to state public benefits only.)
Otherwise Lawfully Present (A.R.S. §§ 1-501 & 1-502)
□ 13. A person not described in categories 1–12 who is otherwise lawfully present in the United States. PLEASE
NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons
who fall into this category ineligible for public benefits despite being lawful present in the United
States. See 8 U.S.C. §§ 1611(a) & 1621(a).
Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 9 of 10
SECTION IV — DECLARATION
All applicants must complete this section. I declare under penalty of perjury under the laws of the state of Arizona
that the answers I have given are true and correct to the best of my knowledge and that the document(s)
submitted demonstrating eligibility and lawful presence are true.
Type of legal residency document(s) provided for applying child: __________________________________
__________________________________________ ___________________________________
PARENT OR LEGAL GUARDIAN’S SIGNATURE DATE
Attachment: List of Evidence of Eligibility and Lawful Presence
Rev 4/20
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signature
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Need help with this application? Contact us: regionalscholarships@vsuw.org or 1-866-973-0012 May 13, 2020
Page 10 of 10
EVIDENCE OF ELIGIBILITY AND LAWFUL PRESENCE
(1) * An Arizona driver license issued after 1996 or an Arizona non-operating identification license (U.S. citizens and
nationals);
(2) A birth certificate or delayed birth certificate issued in any State, Territory, or Possession of the United States, including
the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17,
1917), American Samoa, or the Northern Mariana Islands (on or after November 4, 1986, Northern Mariana Islands local
time) (unless the applicant was born to foreign diplomats residing in such a jurisdiction);
(3) A United States Certificate of Birth Abroad: Consular Report of Birth Abroad of a Citizen of the United States (FS-240)
(issued by the Department of State to U.S. citizens); Certificate of Birth (FS-545) (issued by a foreign service post); or
Certification of Report of Birth (DS-1350) (copies of which are available from the Department of State);
(4) A United States passport;
(5) A foreign passport with a United States visa and appropriate stamp as described below;
(6) An I-94 Form with a photograph and appropriate stamp as described below;
(7) A United States Citizenship and Immigration Services Employment Authorization Document (Form I-766 annotated A3,
A5, or A10; or Form I-551: Permanent Resident Card or Alien Registration Receipt Card) or Refugee Travel Document
(Form I-571);
(8) A United States Certificate of Naturalization (N-550 or N-570);
(9) A United States Certificate of Citizenship (N-560 or N-561);
(10) A Tribal Certificate of Indian Blood; or
(11) A Tribal or Bureau of Indian Affairs Affidavit of Birth.
Tribal members, the elderly and persons with disabilities may contact First Things First at (602) 771-5026 for additional forms of
acceptable evidence.
Acceptable stamps and annotations:
“Qualified Aliens”
Alien Lawfully Admitted for Permanent Residence
- Unexpired Temporary I-551 stamp in foreign passport or on Form I-94.
Asylee or Refugee
- Form I-94 annotated with stamp showing grant of asylum under § 208 or admission under § 207 of the INA.
- Form I-766 (Employment Authorization Document) annotated “A3” or “A5.”
Alien Paroled Into the U.S. for a Least One Year
- Form I-94 with stamp showing admission for at least one year under § 212(d)(5) of the INA. (Applicant cannot aggregate
periods of admission for less than one year to meet the one-year requirement.)
Alien Whose Deportation or Removal Was Withheld
- Form I-766 (Employment Authorization Document) annotated “A10.”
Alien Granted Conditional Entry
- Form I-94 with stamp showing admission under §203(a)(7) of the INA.
- Form I-766 (Employment Authorization Document) annotated “A3.”
Cuban/Haitian Entrant
- Unexpired temporary I-551 stamp in foreign passport or on Form I-94 with the code CU6 or CU7; or
- Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212(d)(5) of the INA.
Battered Aliens, Trafficking Victims, and Iraq/Afghanistan Entrants
Contact First Things First at (602) 771-5026 for assistance.
Nonimmigrants; Aliens Paroled into U.S. for Less than One Year
- Form I-94 with stamp showing authorized admission as nonimmigrant or admission for less than one year under section
212(d)(5) of the INA.
* These documents establish lawful presence for all applicants, but do not guarantee the eligibility of aliens for public benefits.
Therefore, applicants that are not U.S. citizens or nationals must submit an additional or alternate document establishing
eligibility.
Rev 5/19
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Quality First Scholarships Program

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Completed 27 January 2021

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