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
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,
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
4. List all benefit income received from unemployment and
5. List all benefit income received from public assistance (TANF).
6. List income received from an absent parent for child support or
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.
. Check the appropriate box to indicate if activity is work, school
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
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
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-
INSTRUCTIONS FOR COMPLETING SECTION F
After reading the certification, applicant and co-applicant (if
applicable) sign on the appropriate line and include the date.