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MSDE-CCSC MSDE-CCSCENTRAL DOC.221.30 Revised 05/01/2021
Page 1of 6
Maryland State Department of Education/Office of Child Care
Child Care Scholarship Program
APPLICATION/REDETERMINATION FOR CHILD CARE
Return To:
CCS Central 2
PO Box 346031
Bethesda, MD 20827
If you need assistance completing the application, call CCS Central 2 at 1-877-227-0125
Section 1 General Information
Type of Application:
New
Redetermination
Type of Provider Used for Care:
Formal
Informal Relative Care:
Relative Name and Relationship Required
Informal Non-Relative In Child’s Home Care
Section 2 Applicant Information
Name (Last, First, Middle):
Social Security Number (SSN) (optional):
Date of Birth (DOB):
MM/DD/YYYY
Gender:
Female
Male
Marital Status:
Single/Never Married
Divorced
Widowed
Married
Separated
Race:
See choices below
Are you Hispanic/Latino?
Yes
No
Primary Language Spoken in Home:
US Citizen:
Yes
No
Alien Status (if not a citizen):
See choices below
Do you have Active Military Status?
Yes
No
Choices
for
Race:
● American Indian or
Alaskan Native
● Asian
● Black or African
American
● Native Hawaiian or
Pacific Islander
● White
Choices
for
Alien Status:
● Permanent R resident
● Asylee
● Alien Granted Conditional
Entry
● Parolee (1 yr. or more)
● Alien Whose Deportation
is Withheld
● Refugee
● Battered Alien Spouse,
Child or Parent of Child
● Undocumented
● Child of Lawfully Admitted
Alien
Home Address:
Street Apt Number
City State Zip Code County
Mailing Address, if different: Street City State Zip Code
Contact Phone Number: Alternate Contact Phone: Email Address:
Do you pay Child Support to children outside of the home?
Yes
No
Are you a single parent?
Yes
No
Are you a minor parent (under 18)?
Yes
No
Do you receive SNAP (food stamps)?
Yes
No
Do you receive a Housing Subsidy?
Yes
No
Section 3 Need for Care Information
1. Do you receive Temporary Cash Assistance (TCA)?
Yes
No
Never If yes, Start Date:
MM/DD/YYYY
2. Is TCA for the children in your care only?
Yes
No
3. How many people are in your household? Number:
4. What is your annual gross income? Dollar Amount:
5. What is your activity?
Job Search/Work
Community Service
Public School (Elementary, Middle or High School)
College (Undergraduate)
6. Do you want Child Care Assistance for related children who are not
your biological children?
Yes
No
7. How many related children are in your custody? Number:
8. Are you or anyone in your household receiving Supplemental
Security Income (SSI)?
Yes
No
9. Are you responsible for any children with a disability?
Yes
No
10. Are you currently homeless?
Yes
No
11. Do you have assets of one million dollars?
Yes
No
Return by Email To:
CCSCentral2@maryland.gov
Return applications by mail or email. Use one method only.
MSDE-CCSC MSDE-CCSCENTRAL DOC.221.30 Revised 05/01/2021
Page 2 of 6
Section 4 Child Information
C
H
I
L
D
1
Name (Last, First, Middle): Gender:
Female
Male
Date of Birth (DOB):
MM/DD/YYYY
SSN (optional):
Race:
See choices below
Are you Hispanic/Latino?
Yes
No
US Citizen:
Yes
No
Alien Status (if not a citizen):
See choices below
Choices
for
Race:
● American Indian or
Alaskan Native
● Asian
● Black or African
American
● Native Hawaiian or
Pacific Islander
● White
Choices
for
Alien Status:
● Permanent Resident
● Asylee
● Alien Granted
Conditional Entry
● Parolee (1 yr. or more)
● Alien Whose
Deportation is Withheld
● Refugee
● Battered Alien Spouse,
Child or Parent of Child
● Undocumented
● Child of Lawfully
Admitted Alien
1. Is this child receiving Supplemental Security Income (SSI)?
Yes
No
2. What is the child’s relationship to you?
3. Does this child have a disability?
Yes
No
4. Does this child receive benefits from Social Security?
Yes
No
5. Have you applied for child support for this child?
Yes
No If no, please see instructions on page 6.
6. Do you receive child support for this child?
Yes
No
7. What is the name of this child’s absent parent(s)?
8. Is this child in Head Start?
Yes
No
If yes, what is the start date?
MM/DD/YYYY
9. If using Informal Relative Care, what is the relationship of the provider to the child?
Relationship
C
H
I
L
D
2
Name (Last, First, Middle): Gender:
Female
Male
Date of Birth (DOB):
MM/DD/YYYY
SSN (optional):
Race:
See choices above
Are you Hispanic/Latino?
Yes
No
US Citizen:
Yes
No
Alien Status (if not a citizen):
See choices above
1. Is this child receiving Supplemental Security Income (SSI)?
Yes
No
2. What is the child’s relationship to you?
3. Does this child have a disability?
Yes
No
4. Does this child receive benefits from Social Security?
Yes
No
5. Have you applied for child support for this child?
Yes
No If no, please see instructions on page 6.
6. Do you receive child support for this child?
Yes
No
7. What is the name of this child’s absent parent(s)?
8. Is this child in Head Start?
Yes
No
If yes, what is the start date?
MM/DD/YYYY
9. If using Informal Relative Care, what is the relationship of the provider to the child?
Relationship
C
H
I
L
D
3
Name (Last, First, Middle): Gender:
Female
Male
Date of Birth (DOB):
MM/DD/YYYY
SSN (optional):
Race:
See choices above
Are you Hispanic/Latino?
Yes
No
US Citizen:
Yes
No
Alien Status (if not a citizen):
See choices above
1. Is this child receiving Supplemental Security Income (SSI)?
Yes
No
2. What is the child’s relationship to you?
3. Does this child have a disability?
Yes
No
4. Does this child receive benefits from Social Security?
Yes
No
5. Have you applied for child support for this child?
Yes
No If no, please see instructions on page 6.
6. Do you receive child support for this child?
Yes
No
7. What is the name of this child’s absent parent(s)?
8. Is this child in Head Start?
Yes
No
If yes, what is the start date?
MM/DD/YYYY
9. If using Informal Relative Care, what is the relationship of the provider to the child?
Relationship
MSDE-CCSC MSDE-CCSCENTRAL DOC.221.30 Revised 05/01/2021
Page 3 of 6
Section 5 Other Household Members
H
O
U
S
E
H
O
L
D
M
E
M
B
E
R
1
Name (Last, First, Middle): Gender:
Female
Male
Date of Birth (DOB):
MM/DD/YYYY
SSN (optional):
Race: See choices below
Are you Hispanic/Latino?
Yes
No
US Citizen:
Yes
No
Alien Status (if not a citizen):
See choices below
Choices for
Race:
● American Indian or
Alaskan Native
● Asian
● Black or African American
● Native Hawaiian or
Pacific Islander
● White
Choices for
Alien Status:
● Permanent Resident
● Asylee
● Alien Granted Conditional
Entry
● Parolee (1 yr. or more)
● Alien Whose Deportation
is Withheld
● Refugee
● Battered Alien Spouse,
Child or Parent of Child
● Undocumented
● Child of Lawfully Admitted
Alien
Are you Active Military Status?
Yes
No
Primary Language:
Relationship to Applicant: See choices below
Choices for
Relationship
to Applicant:
● Adopted Child
● Biological Child
● Sibling
● Stepchild
● Cousin
● Foster Care Child
● Grand/Great Grandchild
● Niece/Nephew
● Ward
● Other (Related)
● Other (Not Related)
1. Does household member have an activity that makes them unavailable to care for the child?
Yes
No
2. Does household member have earned or unearned income?
Yes
No
3. Is there a circumstance that makes the household member unable to care for the child?
Yes
No
H
O
U
S
E
H
O
L
D
M
E
M
B
E
R
2
Name (Last, First, Middle): Gender:
Female
Male
Date of Birth (DOB):
MM/DD/YYYY
SSN (optional):
Race:
See choices above
Are you Hispanic/Latino?
Yes
No
US Citizen:
Yes
No
Alien Status (if not a citizen):
See choices above
Are you Active Military Status?
Yes
No
Primary Language:
Relationship to Applicant: See choices above
1. Does household member have an activity that makes them unavailable to care for the child?
Yes
No
2. Does household member have earned or unearned income?
Yes
No
3. Is there a circumstance that makes the household member unable to care for the child?
Yes
No
H
O
U
S
E
H
O
L
D
M
E
M
B
E
R
3
Name (Last, First, Middle): Gender:
Female
Male
Date of Birth (DOB):
MM/DD/YYYY
SSN (optional):
Race:
See choices above
Are you Hispanic/Latino?
Yes
No
US Citizen:
Yes
No
Alien Status (if not a citizen):
See choices above
Are you Active Military Status?
Yes
No
Primary Language:
Relationship to Applicant: See choices above
1. Does household member have an activity that makes them unavailable to care for the child?
Yes
No
2. Does household member have earned or unearned income?
Yes
No
3. Is there a circumstance that makes the household member unable to care for the child?
Yes
No
H
O
U
S
E
H
O
L
D
M
E
M
B
E
R
4
Name (Last, First, Middle): Gender:
Female
Male
Date of Birth (DOB):
MM/DD/YYYY
SSN (optional):
Race:
See choices above
Are you Hispanic/Latino?
Yes
No
US Citizen:
Yes
No
Alien Status (if not a citizen):
See choices above
Are you Active Military Status?
Yes
No
Primary Language:
Relationship to Applicant: See choices above
1. Does household member have an activity that makes them unavailable to care for the child?
Yes
No
2. Does household member have earned or unearned income?
Yes
No
3. Is there a circumstance that makes the household member unable to care for the child?
Yes
No
MSDE-CCSC MSDE-CCSCENTRAL DOC.221.30 Revised 05/01/2021
Page 4 of 6
Section 6 Activity Information
A
C
T
I
V
I
T
Y
1
Applicant/Household Member Name (from Section 2 or 5):
Activity Type: See choices below
Choices for
Activity Type:
● Job Search
● Community Service
● Education
● Employment
● Training
● FIA Personal Responsibility Plan
Name of Organization: Organization Phone Number:
Organization Address:
Street
City
State
Zip Code
If you do not have a standard activity
schedule, enter total hours per week:
Enter daily commute time from provider
to activity (to and from):
Activity
Hours
Sunday
To
Monday
to
Tuesday
to
Wednesday
to
Thursday
to
Friday
to
Saturday
to
A
C
T
I
V
I
T
Y
2
Applicant/Household Member Name (from Section 2 or 5):
Activity Type: See choices above
Name of Organization: Organization Phone Number:
Organization Address:
Street
City
State
Zip Code
If you don’t have a standard activity
schedule, enter total hours per week:
Enter daily commute time from provider
to activity (to and from):
Activity
Hours
Sunday
To
Monday
to
Tuesday
to
Wednesday
to
Thursday
to
Friday
to
Saturday
to
A
C
T
I
V
I
T
Y
3
Applicant/Household Member Name (from Section 2 or 5):
Activity Type: See choices above
Name of Organization: Organization Phone Number:
Organization Address:
Street
City
State
Zip Code
If you do not have a standard activity
schedule, enter total hours per week:
Enter daily commute time from provider
to activity (to and from):
Activity
Hours
Sunday
To
Monday
to
Tuesday
to
Wednesday
to
Thursday
to
Friday
to
Saturday
to
For all activities that are “Employment,” you must attach a letter from the employer on company letterhead verifying work hours.
For all activities that are “Education” or “Training,” you must attach a copy of the current school/training schedule on school
letterhead to verify days and hours of classes.
Section 7 Child Care Schedule
School Aged Children: If care schedule is not provided, the child will be issued a one unit scholarship (15 hours per week)
If you do not have a standard child care schedule, enter total hours per week:
What are the specific days and hours you need child care each day based on your activity?
Child
One
Sunday
To
Monday
to
Tuesday
to
Wednesday
to
Thursday
to
Friday
to
Saturday
to
If you do not have a standard child care schedule, enter total hours per week:
What are the specific days and hours you need child care each day based on your activity?
Child
Two
Sunday
To
Monday
to
Tuesday
to
Wednesday
to
Thursday
to
Friday
to
Saturday
to
If you do not have a standard child care schedule, enter total hours per week:
What are the specific days and hours you need child care each day based on your activity?
Child
Three
Sunday
To
Monday
to
Tuesday
to
Wednesday
to
Thursday
to
Friday
to
Saturday
to
MSDE-CCSC MSDE-CCSCENTRAL DOC.221.30 Revised 05/01/2021
Page 5 of 6
Section 8
Income Information
I
N
C
O
M
E
1
Name of Household Member with Income: Type of Income: See choices below
Choices for
Type of Income:
● Alimony
● Armed Services Pay
● Child Support – Court Ordered
● Child Support – Voluntary
● SS Benefits
● SSI
● Self-Employment Gross
● TCA
● Tips/Commission Pay
● Unemployment
● Veterans Assistance/Benefit
● Wage/Salary
● Workers Compensation
● Other
How often does Household Member receive the income? Gross income each time Household Member is paid ($):
If the income is Child Support, what is the name of the absent parent paying it?
I
N
C
O
M
E
2
Name of Household Member with Income: Type of Income: See choices above
How often does Household Member receive the income? Gross income each time Household Member is paid ($):
If the income is Child Support, what is the name of the absent parent paying it?
I
N
C
O
M
E
3
Name of Household Member with Income: Type of Income: See choices above
How often does Household Member receive the income? Gross income each time Household Member is paid ($):
If the income is Child Support, what is the name of the absent parent paying it?
I
N
C
O
M
E
4
Name of Household Member with Income: Type of Income: See choices above
How often does Household Member receive the income? Gross income each time Household Member is paid ($):
If the income is Child Support, what is the name of the absent parent paying it?
Attach proof of last 4 weeks of all income for: applicant, spouse, other parent in home, parents of minor parent, adult and spouse with physical custody of
minor child.
MSDE-CCSC
Page 6 of 6
Your application gives us information about whether you are eligible for benefits and services. These benefits are provided at public expense and you must
give true information. It may be verified with public and private agencies and businesses. You must report any changes to the information provided on this
form within 10 days of the change. If you knowingly give false information or willfully fail to report changes you may be subject to disqualification and to the
penalties listed below.
Section 8-504 of the Criminal Law Article of the Maryland Annotated Code states that:
(a) Any person who fraudulently obtains, attempts to obtain, or aides another person in fraudulently obtaining or attempting to obtain money, property,
food stamps, medical care, or other assistance to which he is not entitled, under a social, health, or nutritional program based on need, financed in
whole or in part by the State of Maryland, and administered by the state or its political subdivisions is guilty of a misdemeanor. For purpose of this
section, fraud shall include:
(1) willfully making a false statement or representation; or
(2) willfully failing to disclose a material change in household or financial condition; or
(3) impersonating another person.
(b) Upon conviction, after notice and the opportunity to be heard as to the amount of payment and how the payment is to be made, the person shall
make full restitution of the money, property, food stamps, medical care or other assistance unlawfully received, or the value thereof, and shall be
fined not more than $1,000 or imprisoned for not more than three years, or both fined and imprisoned.
Consent to Release Information:
I hereby authorize the Maryland State Department of Education Child Care Scholarship Unit (MSDE/CCS), the Maryland State Department of Human
Resources Office of Inspector General (DHR/OIG) or any entities authorized by MDSE to contact, review and obtain records maintained by any person,
partnership, corporation, association, or governmental agency for the purpose of establishing proof of my eligibility for CCS benefits. This includes but is not
limited to: employment, financial (including bank records), school/educational, rental/housing and Maryland State Income Tax records. By signing below, I
certify that I am the undersigned, I am competent to consent to this release of information and that I give MSDE/CCS permission to provide program
information by email and/or text message. A photocopy of this form is as valid as the original.
Parent Name Printed Date
Parent Signature Date
Other Parent Name (Parent/Spouse in the Household or Parent of Minor Child) Printed Date
Signature of Other Parent (Parent /Spouse in the Household or Parent of Minor Child) Date
APPLICATIONS NOT SIGNED AND DATED WILL BE RETURNED.
Electronic signatures are accepted if application is submitted through the CCS Central 2 online parent/provider portal.
Date of application must be within 45 days of submission. Do not submit redeterminations prior to 45 days of redetermination end date
Report suspected fraud of the Child Care Scholarship Program at Reportccsfraud.org
MSDE-CCSCENTRAL DOC.221.30 Revised 05/01/2021
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Completed 24 August 2021

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