Fillable Service Eligibility Application Child Care and Early Education

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Service Eligibility Application Child Care and Early Education

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Child Care and Early Education
Service Eligibility Application
STATE OF NEW JERSEY ● DEPARTMENT OF HUMAN SERVICES
Applicant Instructions for Completing the Child Care Eligibility Form
The following instructions are keyed to the various sections of this form. Please read carefully.
INSTRUCTIONS FOR COMPLETING SECTION A
1. Enter your full name (last, first, middle initial), social security
number and date of birth (month/date/year). Check one or more
of the appropriate boxes provided to indicate your race. Check
the appropriate box to indicate your ethnicity and sex. Check the
appropriate box to indicate the relationship of the parent/
applicant to the child(ren) for which you are making an
application for assistance. If you are not an immediate relative
(mother/father), please indicate whether you are another legally
responsible person, a foster parent or other. If other, please
specify.
2. If applicable (resides in household), enter the full name of your
spouse or co-applicant, social security number and date of birth
(month/date/year). Check the appropriate boxes provided to
indicate the race, ethnicity and sex of the co-applicant/spouse.
3. Enter your home address and county in which you reside. Enter
the school district which the child(ren) attends.
4. Enter your home telephone number.
5. Enter the “family size” meaning the number of adults (persons
18 years or older who are legally responsible for the children)
and dependent adults (persons 18 years or older) who are in
your immediate family unit, and the number of dependent
children (persons under age 18).
Examples: In a single parent family with two children state:
“# of Adults: 1, # of Children: 2.”
In a two parent family with a dependent adult (grandparent) and
two children state: “# of Adults: 3, # of Children: 2.”
Note: If as a single parent, you and your child(ren) live with your
mother and father, you would NOT include the grandparents in
the family size.
INSTRUCTIONS FOR COMPLETING SECTION B
Provide Income Information Based on the Current Year.
Fill In All Blanks. List Gross Figures Unless Otherwise
Indicated. If You Receive None in a Certain Category,
Write “0.”
For each adult (applicant co-applicant or other dependent adult)
residing in the household unit, list all current income information.
Columns are provided to enter income information either by week,
every two weeks, month or year. For separated or divorced spouses,
include only that income (i.e., child support or alimony) which is
available to the custodial family.
1. List all gross income due to wages and salary.
2. List all benefit income received from pensions and retirement.
3. List all benefit income received from Supplemental Security
Income (SSI).
4. List all benefit income received from unemployment and
workmen’s compensation.
5. List all benefit income received from public assistance (TANF).
6. List income received from an absent parent for child support or
alimony.
7. Include any other income received which is required to be listed
for federal and state tax reporting purposes.
8. Indicate the annual total of all sources of income.
INSTRUCTIONS FOR COMPLETING SECTION C
Provide Information of Current Work, School and/or Training
Activity for Applicant and Co-Applicant (if applicable).
1. Enter the name, complete address and telephone number of
Primary Work/School/Training Site.
2
. Check the appropriate box to indicate if activity is work, school
or training.
3.
Enter your starting date (month/date/year).
4. Check the appropriate box to indicate if Work/School/Training
activity is full time, part time or seasonal. Enter the number of
hours per week and months per year spent at site.
5. Include the information for your Secondary Work/School/Training
activity (if applicable).
INSTRUCTIONS FOR COMPLETING SECTION D
Questions 1-9. Check the appropriate box (either “Yes” or “No”)
for each question. If you answer “Yes” to any of questions 2-5,
provide the requested information.
Questions 10.Check the appropriate box to indicate if you are
applying for assistance because you are ineligible for the TANF or
TCC programs.
Questions 11. Check whether you understand you are applying
for voucher or contracted child care services.
Questions 12.Check whether all of the children in your family have
health insurance and if you wish to receive an application for NJ
Family Care.
INSTRUCTIONS FOR COMPLETING SECTION E
1-2. Enter full name (last, first, middle initial), social security number
and date of birth (month/date/year) for each child for whom
assistance is requested. Check the appropriate boxes provided to
indicate race, ethnicity and sex of child(ren). Indicate the hours,
days and duration for which child care is needed. Check the
appropriate box to indicate if the child(ren) has a special need, if
yes, state the need. Check the appropriate box to indicate if the
child is a US citizen. If yes, attach a copy of the child’s birth certificate
and social security card. Proof of the child’s citizenship is not
required for Abbott, Child Protective Services, Kinship or Post-
Adoption sibsidies.
INSTRUCTIONS FOR COMPLETING SECTION F
After reading the certification, applicant and co-applicant (if
applicable) sign on the appropriate line and include the date.
Rev 12/08
1. PARENT/APPLICANT NAME SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
Relationship of APPLICANT to children: Father Mother Legally Responsible Adult Foster Parent Other:
2. PARENT/CO-APPLICANT NAME (If Applicable) SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
3. HOME ADDRESS (Number and Street)
City: State: Zip Code:
County: School District:
4. HOME TELEPHONE:
5. NUMBER OF ADULTS IN FAMILY: NUMBER OF CHILDREN IN FAMILY: TOTAL FAMILY SIZE:
Family size includes parent, spouse, children for whom subsidy is requested, other dependent children, or adults claimed on applicant’s or co-
applicant’s IRS 1040. In cases of kinship, family size includes the child for whom subsidy is requested and all dependents claimed on the
grandparent’s, aunt’s or relative’s IRS 1040. For DYFS cases, a child and any of his/her siblings living in the same home and who are in DYFS-
paid out of home placement shall be counted to determine the size of the family.
PARENT/APPLICANT
List gross income for current:
WEEK 2 WEEKS MONTH YEAR
Child Care and Early Education
Service Eligibility Application
STATE OF NEW JERSEY ● DEPARTMENT OF HUMAN SERVICES
Please Read Instructions, Print Clearly, Answer All Questions
For each source, enter income information
either by week, bi-weekly, month or year.
Include child support and/or alimony.
1. Wages and Salary (gross):
2. Pensions, Retirement:
3. Supplemental/Social Security Benefits:
4. Unemployment, Workmen’s Compensation:
5. TANF Cash Assistance:
6. Child Support/Alimony:
7. Other:
8. TOTAL GROSS INCOME:
Name of PRIMARY Work/School/Training Site:
Complete Address (Street, City, State, & Zip.:
(If applicable, enter “Self-Employed”)
Telephone Number:
Check One: Enter Starting Date (Mo/Dy/Yr):
Check One and Enter: Number of Hours/
Week and Months/Year for Work/School/Training
PARENT/APPLICANT
Applicant/Co-Applicant Information
Family Income Information
Work/School/Training Information
Attach Original Proof of Income - Most Recent Four Consecutive Weeks
Information is not required for DYFS-paid caregivers. Payments for DYFS children in out of home placement does not count as income.
Proof of Current School Registration Must Be Attached
PARENT/CO-APPLICANT
PARENT/CO-APPLICANT
List gross income for current:
WEEK 2 WEEKS MONTH YEAR
ADDRESS REPLY TO:
Programs for Parents, Inc
570 Broad Street 8th Floor
Newark, NJ 07102
A
/
//
B
C
( )
Work School Training
Start Date
Full Time Part Time # Hrs/Wk
Seasonal Employment # Mos/Yr
//
Name of SECONDARY Work/School/Training Site:
Complete Address (Street, City, State, & Zip.:
Telephone Number:
Check One: Enter Starting Date (Mo/Dy/Yr):
Check One and Enter: Number of Hours/
Week and Months/Year for Work/School/Training
( )
Work School Training
Start Date
Full Time Part Time # Hrs/Wk
Seasonal Employment # Mos/Yr
//
( )
Work School Training
Start Date
Full Time Part Time # Hrs/Wk
Seasonal Employment # Mos/Yr
//
( )
Work School Training
Start Date
Full Time Part Time # Hrs/Wk
Seasonal Employment # Mos/Yr
//
* Incomplete Applications Will Not Be Accepted *
DHS/CC:1 (12/08)
/
FULL NAME OF CHILD NO. 1 SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
Indicate the hour/days/duration for which child care is needed:
Child
has
a
special
need: No Yes If
yes,
state
special
need
and attach
verification:
Child is a US citizen or a qualified alien? No Yes If
yes,
attach
verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE:
Status (Check One): Denied Approved Waiting List Pending
DYFS USE:
(Enter the NJ Spirit Case No.)
Program: Code: Component:
Assessed Co-Payment (Enter and Circle One): $ Wk. Mo. Enrollment Date:
FULL NAME OF CHILD NO. 2 SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
Indicate the hour/days/duration for which child care is needed:
Child
has
a
special
need: No Yes If
yes,
state
special
need
and attach
verification:
Child is a US citizen or a qualified alien? No Yes If
yes,
attach
verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE:
Status (Check One): Denied Approved Waiting List Pending
DYFS USE:
(Enter the NJ Spirit Case No.)
Program: Code: Component:
Assessed Co-Payment (Enter and Circle One): $ Wk. Mo. Enrollment Date:
FULL NAME OF CHILD NO. 3 SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
Indicate the hour/days/duration for which child care is needed:
Child
has
a
special
need: No Yes If
yes,
state
special
need
and attach
verification:
Child is a US citizen or a qualified alien? No Yes If
yes,
attach
verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE:
Status (Check One): Denied Approved Waiting List Pending
DYFS USE:
(Enter the NJ Spirit Case No.)
Program: Code: Component:
Assessed Co-Payment (Enter and Circle One): $ Wk. Mo. Enrollment Date:
1. Are you currently participating in the Food Stamp Program?
2. Are you currently receiving/have you received assistance for child care with a Temporary Assistance for Needy Families (TANF) or
Transitional Child Care (TCC) grant through the Work First New Jersey (WFNJ) Program within the last two years? If yes, indicate when
benefits do/did expire by entering Month, Day and Year and TANF case number:
3. Is your family an active case with the Division of Youth and Family Services (DYFS) and are the children for whom you are requesting
subsidy residing with you? If yes, please give the name of the office:
4. Are you currently receiving a TANF grant? If yes, please indicate the TANF case number:
5. Do you or a member of your family have a chronic medical problem for which child care is recommended as part of a treatment/rehabilitation
plan? If yes, indicate the name of the individual/agency authorizing the treatment plan and telephone number:
Agency Name: Telephone #: ( )
6. Are you the head of the household in which you reside?
7. Are you currently homeless or at risk of becoming homeless?
8. Are the children for whom you are requesting child care assistance in a DYFS foster home, DYFS para-foster home, or DYFS pre-adoptive
home. If you are employed or participating in a school or training program, proof must be attached for DYFS purposes.
9. Do you receive any cash or voucher assistance to specifically pay for housing?
10. Are you requesting assistance because the County Welfare Agency/Board of Social Services (CWA/BSS) informed you that you are
ineligible for the Temporary Assistance for Needy Families (TANF) or Transitional Child Care (TCC) Program?
11. I understand that I am applying to the agency for:
VOUCHER
payment assistance CONTRACTED services in a comunity-based center
12. Do all of the children in this family have health insurance benefits? Yes No
If NO, do you wish to receive an application for NJ
Family Care?
Yes No
Children
Information
All Questions Must Be Answered. Incomplete Applications Will Not Be Accepted.
Supporting Documents Must Be Attached For Varification
YES NO
D
E
Include Each Child Needing Child Care Service and for Whom Assistance Requested.
Use Addendum Form to Provide Information for Addiitonal Children.
//
//
//
//
//
//
You May Be Required to Provide Additional Proof of Family Size, Income, Citizenship or Residency to Verify Eligibility.
Supporting Documentation Required May Include Most Current IRS Form 1040, Utility Bill or Birth Certificate.
DHS/CC:2 (12/08)
FULL NAME OF CHILD NO. 4 SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
Indicate the hour/days/duration for which child care is needed:
Child
has
a
special
need: No Yes If
yes,
state
special
need
and attach
verification:
Child is a US citizen or a qualified alien? No Yes If
yes,
attach
verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE:
Status (Check One): Denied Approved Waiting List Pending
DYFS USE:
(Enter the NJ Spirit Case No.)
Program: Code: Component:
Assessed Co-Payment (Enter and Circle One): $ Wk. Mo. Enrollment Date:
FULL NAME OF CHILD NO. 5 SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
Indicate the hour/days/duration for which child care is needed:
Child
has
a
special
need: No Yes If
yes,
state
special
need
and attach
verification:
Child is a US citizen or a qualified alien? No Yes If
yes,
attach
verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE:
Status (Check One): Denied Approved Waiting List Pending
DYFS USE:
(Enter the NJ Spirit Case No.)
Program: Code: Component:
Assessed Co-Payment (Enter and Circle One): $ Wk. Mo. Enrollment Date:
FULL NAME OF CHILD NO. 6 SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
Indicate the hour/days/duration for which child care is needed:
Child
has
a
special
need: No Yes If
yes,
state
special
need
and attach
verification:
Child is a US citizen or a qualified alien? No Yes If
yes,
attach
verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE:
Status (Check One): Denied Approved Waiting List Pending
DYFS USE:
(Enter the NJ Spirit Case No.)
Program: Code: Component:
Assessed Co-Payment (Enter and Circle One): $ Wk. Mo. Enrollment Date:
FULL NAME OF CHILD NO. 7 SOCIAL SECURITY NO. DATE OF BIRTH
(Last) (First) (M.I.) (9 Digit Number) (Mo./Dy./Yr.)
The following information is needed for statistical purposes. Check one or more of the appropriate boxes to indicate applicant response.
RACE: American Indian or Alaskan Asian Black or African American Native Hawaiian/Pacific Islander White
ETHNICITY: Hispanic/Latino: Yes No SEX: Male Female
Indicate the hour/days/duration for which child care is needed:
Child
has
a
special
need: No Yes If
yes,
state
special
need
and attach
verification:
Child is a US citizen or a qualified alien? No Yes If
yes,
attach
verification (copy of Social Security Card and Birth Certificate or,
if applicable, Resident Alien Card)
AGENCY USE:
Status (Check One): Denied Approved Waiting List Pending
DYFS USE:
(Enter the NJ Spirit Case No.)
Program: Code: Component:
Assessed Co-Payment (Enter and Circle One): $ Wk. Mo. Enrollment Date:
Child Care and Early Education
Service Eligibility Application
STATE OF NEW JERSEY ● DEPARTMENT OF HUMAN SERVICES
ADDRESS REPLY TO:
Parent/Applicant Name:
Social Security Number:
Date of Birth:
//
Complete for Each Additional Child for Whom You Are Requesting Subsidy
4
//
//
//
//
5
//
//
//
//
6
7
DHS/CC:2A (12/08)
DYFS Voucher Payment Authorization Signature: Date:
CCR&R or CENTER-BASED CONTRACTED (CBC) PROVIDER USE ONLY:
Check One: Initial Application Re-determination Certification Date:
Family Size: Annual Family Income: $
Family’s Total Assessed Co-Payment, if applicable (Enter Amt. and Check One): $ WEEK MONTH
Check One: DENIED APPROVED PENDING
Staff Member Certification: Date:
Note:
Name of CCR&R or CBC Provider:
Child Care and Early Education Service Eligiblity Application Certification
READ CAREFULLY BEFORE SIGNING
I (we) hereby certify that all of the information provided is true and correct to the best of my (our) knowledge. I (we) know that submitting
false information about my (our) situation, failing to give the necessary information or causing others to hold back information is
against the law and may subject me (us) to prosecution. I (we) also understand that:
1. Acceptance of child care financial assistance is not for my (our) personal use or expenses and that federal, state and local public
funds are and will be used as payment for costs that are directly associated with services rendered by a child care provider.
2. It is unlawful to obtain financial assistance for child care services by providing any false or misleading information, including but not
limited to information about my eligibility and/or information that relates to child attendance for provider records, sign-in sheets or
voucher payment forms. Examples of unlawful behavior include, but are not limited to:
• Failing to accurately report all sources of my (our) income. Examples include, but are not limited to not reporting multiple
sources of income, or an increase or decrease in wage/salary, child support payments, or alimony, or any other income.
• Failing to accurately report the amount of my income. Examples include, but are not limited to reporting the accurate amount(s)
of income from self-employment; rent from property ownership or changing or altering pay stub information.
• Failing to accurately report the number of household members. Examples include, but are not limited to failing to report that
my spouse or another parent/guardian is living in the household.
• Pre-signing and dating voucher certification forms, sign-in sheets or other provider records used to track and verify child
attendance.
• Failing to accurately verify child attendance on voucher payment records/forms within the reporting timeframes.
3. This information is being given in connection with federal, state and local public funds and will be used through computer matching
programs to confirm the accuracy of my (our) statements and verify my (our) income, resources and need for child care assistance,
as warranted.
4. Providing the requested information, including the Social Security Numbers of Parent(s)/Applicant(s), is voluntary. Agency staff may
use my (our) names and Social Security information with federal and state agencies and other sources deemed necessary for
official examination. However, copies of birth certificates, social security and qualified alien resident cards, if applicable, are
required for all children for whom subsiday services are being requested.
5. Failure to provide or deliberate misrepresentation of required information will result in the denial of my (our) application, termination
of child care benefits to the family and referral to federal, state or local agencies for criminal or civil court action, garnishment of
wages or tax intercept, as well as private claims collection agencies for claims action involving repayment and recovery of funds.
6. Providing false or misleading information in connection with my (our) application for child care financial assistance, and/or failing
to report within ten days any change in my (our) family size or family income or any other circumstances that might change my (our)
eligibility, such as work/school/training status, may result in the termination of my (our) child care subsidy and make me (us)
ineligible to apply for and/or receive subsidized child care for a period of six months for the first violation; for a period of 12 months
for a second violation; and permanent disqualification for the third violation.
7. If I receive financial assistance as a result of false or misleading information, I (we) may be responsible to repay the costs of child
care and may be subject to a civil fine and possible criminal prosecution.
8. I (we) understand that in order to verify my (our) income and service need, an agency representative may need to contact my (our)
employer(s). I (we) hereby authorize my (our) employer(s) to release information regarding my (our) income, pay scale, hours and
schedule of work to the agency to which I am applying.
Parent/Guardian Signature: Date:
Parent/Guardian Signature: Date:
F
Unsigned applications cannot be processed. A copy of this document will be provided to you for your records.
DYFS USE ONLY
DYFS Case Manager Name and Number: Date:
Note:
SAR has been completed; voucher payments for DYFS/CPS child care services are approved for the period thru
//
//
//
DHS/CC:3 (12/08)
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
1
NJ CHILD CARE SUBSIDY PROGRAM
Documentation Checklist
Below is a general list of required documents for each section of the Child Care Subsidy Program Application that must
be submitted for initial eligibility consideration. Additional documents may also be required based on program
requirements. Please contact and check with the Child Care Resource and Referral Agency (CCR&R) if you have
questions or need assistance. You can reach your local CCR&R at 1-800-332-9227 or by visiting www.ChildCareNJ.gov.
IDENTIFICATION
For each applicant/co-applicant, submit one of the documents from Column A. If you are unable to provide from
Column A, you may submit two documents from Column B:
COLUMN A (PRIMARY DOCUMENTATION)
Submit one:
OR
COLUMN B (SECONDARY DOCUMENTATION)
Submit two:
Driver’s License
Government Issued Photo ID Card
Military Photo ID Card
Employer Issued Photo ID
School Photo ID
Passport
Permanent Resident Card (Green Card)
High School Diploma, GED, or College Diploma
Health Insurance Card or Prescription Card
Printed Paystub
Birth Certificate (applicant/co-applicant or child’s)
Social Security Card
ADDRESS
For any applicant/co-applicant, submit one of the following to verify residence*:
Current Rental/Lease Agreement or Mortgage Bill
Court decree (if applicable)
School records showing residence
Custody Agreement or other court documents for
guardianship
Home utility bills
Medical documentation
Vehicle Registration or Title or NJ Driver’s License
Most recent filed tax forms showing dependency
(For dependents 18+, must provide filed IRS 1040 Form)
*If you or your child are homeless and do not have a fixed address, please contact your CCR&R for assistance.
RELATIONSHIP AND HOUSEHOLD SIZE
For any child in need of child care services, submit the following to prove relationship:
Child’s Birth Certificate
Court decree (if applicable)
Custody Agreement or other court documents for guardianship (if applicable)
For each dependent residing in the home and included in the family size, submit one of the following to verify family size:
Birth Certificate
Custody Agreement or other court documents for
guardianship (if applicable)
Court decree (if applicable)
Most recent filed tax forms showing dependency
(For dependents 18+, must provide filed IRS 1040 Form)
2
NJ CHILD CARE SUBSIDY PROGRAM
Documentation Checklist Continued
CHILD CITIZENSHIP STATUS

For any child in need of care, submit one of the following:
U.S. Birth Certificate
Certificate of Citizenship
U.S. Passport or Passport Card
Social Security Card
Permanent Resident Card (Green Card)
USCIS Form I-551 (Alien Registration Card)
Refugee Travel Document (Form I-571)
USCIS/INS Form I-94 stamped “Refugee”, “Parolee”,
“Asylee”, or “Notice of Action”
INCOME

INCOME FROM EMPLOYMENT:
OTHER INCOME OR BENEFITS TO FAMILY UNIT:
Must provide current one month’s worth of current pay
stubs (e.g. 4 weekly, 2 biweekly, etc.)
NEW EMPLOYMENT ONLY: If paystubs are not available
Employer letter on company letterhead (signed/dated)
Must include rate of pay, hours worked per week,
employer contact information, and first date of
employment; or
DFD “Verification of Employment” Form
If approved for subsidy, applicant/co-applicant will
be required to follow up with pay stubs.
SELF-EMPLOYED ONLY: Submit Current IRS Tax
Transcript of Form 1040 Schedule C, “Profit or Loss
from Business”
UNABLE TO WORK or INCAPACITATED: DFD
“Parent Incapacitation Verification” Form
Documentation must show the rate and frequency of the
income received from the sources below:
Unemployment documentation
Pension documentation
Worker’s Compensation
Social Security award letter
Retirement/Pension
Spousal Support/Alimony
Veterans/Military Benefits
Disability Benefits
Child Support – minimum of 6 months of
Payment/Disbursement History
(Note: If child support or alimony is not court ordered, write the
amount you receive monthly in Section C of the application)
Any other income required for federal/state tax
reporting purposes
SCHOOL/TRAINING
For each applicant/co-applicant, submit one of the following:
SCHOOL: Detailed school schedule naming the school and the student, including days and hours attending, credits,
start and end date
TRAINING PROGRAM:Letter on Program letterhead (signed/dated) indicating name of program, start and end
date and weekly schedule
DFD 10
-
17
Dear applicant:
When applying for the Child Care Assistance Program (CCAP, please be sure to include
the following for you and your co-applicant (if a two (2) parent household):
If employed, submit paystubs (4) pay stubs (copies or originals) if you get paid weekly, two (2) if
you get paid bi-weekly The four (4) weeks of paystubs can be, non consecutive paystubs received within
six (6) weeks prior to the day the application is received at PfP.
If your pay stubs do not show the number of hours that you work per week in addition to the pay
stubs, submit an ORIGINAL letter from your employer on company letterhead, including the number of
hours that you work per week and your GROSS INCOME. The letter must be current within the last 30
calendar days, it must be signed and include the signer’s name, title and a phone number.
If you do not receive pay stubs because you have direct deposit, printouts from the internet are
acceptable. If the printouts do not show the number of hours that you work per week, in addition to the
printouts, submit an ORIGINAL letter from your employer on company letterhead, including the
number of hours that you work per week and your GROSS INCOME. The letter must be current within
the last 30 calendar days, it must be signed and include the signer’s name, title and a phone number.
The stubs/printouts and the original letter should show a minimum of thirty (30) hours or more
per week to be eligible.
If you are a full time student or participating in a job-directing training/program, submit an
ORIGINAL letter from the school registrar’s office or the school/training director including the number
of credits you are taking and the semester start and end dates. If your school does not verify credits, or
you are enrolled in training then the letter must indicate the number of hours you attend school per week
and the start and end date of the program. You can also submit a copy of your registration or school
schedule for the semester printed from the student’s portal.
The original letter from school/training must indicate you are enrolled/attend school a
minimum of 12 credits per semester or 20 hours per week to be eligible.
If you are a part time student or participating in a job-directing training/program less than 20
hours but you are also working part time, you may still be eligible. Submit verification of both
following instructions listed above to verify employment and school.
If receiving unemployment and enrolled in school and/or training, submit proof of income for the
four (4) weeks prior to the date your application is received.
SEE THE BACK OF THIS PAGE FOR ADDITIONAL INFORMATION
If receiving TANF, a grant letter from your caseworker to confirm the amount of your grant if
enrolled in school and/or training.
If receiving Supplemental/Social Security Benefits, submit a letter from the Social Security Office
stating the monthly amount if enrolled in school and/or training.
If receiving child support, submit a copy of court order if enrolled in school and/or training. If you
do not have a court order, current NOTIRIZED letter from the non-custodial parent dated within the last
30 days prior to the date your application is received indicating amount received and frequency of
payments; or affidavit from you indicating the amount received and the frequency.
Applications should be submitted with the following documents:
- Copies of ALL children’s birth certificates listed on the application as proof of US Citizenship or
documents validating their status as a qualified alien to reside in the USA.
- Copies of Social Security cards for ALL children listed on the application. If a child has not
received a number yet, send proof of application from the Social Security office.
- If you indicated on your application that your child(ren) has/have special needs, submit a
certified/signed document from the health professional/ institution stating that special services are
required as part of a treatment plan to stabilize or/and improve the child (ren)’s condition.
SUBMITTING THE NEEDED INFORMATION WILL EXPIDITE THE
DETERMINATION OF YOUR ELIGIBILITY
If determined eligible, and approved to receive a subsidy, you MUST inform PfP of any
changes in your family circumstances that affect your eligibility, within ten (10) calendar
days from the occurrence, these changes may include but are not limited to:
Household income.
Employment. ( different employer, unemployment, etc)
Number of working hours per week ( less than 30)
Family size (marital status, birth of a child, etc)
Period of time you will be absent from work (medical reason, maternity leave,
approved leave, etc)
If you stop attending school/training.
Place of residency (address, street, town, city, state, etc)
If you have any questions, or wish to schedule an appointment to have your application
reviewed in person, please contact us at 973-297-1114 or contact us via e-mail at
customerservice@proramsforparents.org.
INCOMPLETE APPLICATIONS WILL BE DETERMINED INELIGIBLE.
Parents of
Essex County…
You may be
eligible to enroll
your children in a
FREE
pre-school
program!
If you live in any of the towns listed below,
you may qualify.
Contact your local school board immediately by calling:
East Orange: 973-676-1869 Newark: 973-733-6234
973-676-1873
973-676-3687
973-676-3807
Irvington: 973-399-3942 Orange: 973-677-4015
Or call toll free: 1-800-332-9227
New Jersey Department of Human Services
Division of Family Development
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Service Eligibility Application Child Care and Early Education

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Completed 25 March 2021

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