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Online Child Care Subsidy Application

Childcare Eligibility Application

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General Info

Please complete all sections of this form accurately. This information will be used to determine your placement on the subsidized eligibility list.

As monies become available, you will be contacted for an eligibility appointment. If your address, phone number, income, family size or any other information changes, please contact ICES to update your information.

DO NOT SEND any documentation (including copies of pay stubs). This documentation will be discarded. You will be notified if and when any additional documentation is required.

Please feel free to contact ICES if you have any questions.

APPLICANT INFORMATION

Applicant Name

Last, First, Middle Initial

Applicant Date of Birth

Applicant Gender

Male
Female

Applicant Home Address

Street Address, Apartment #, City, Zip Code

Applicant Mailing Address

Street Address, Apartment #, City, Zip Code (if different than home address)

Applicant Phone

Applicant Cell/Msg

Applicant E-mail Address

If Other, please explain:

Is the second parent to at least one of the children living in the home?

Yes
No

Total # in Family

SECOND PARENT INFORMATION (Complete this section ONLY if second parent currently lives in the home)

Second Parent Name

Last, First, Middle Initial

Second Parent Date of Birth

Second Parent Gender

Male
Female

Second Parent Cell/Msg

Second Parent Email

NEED FOR CARE

Why do you need services? (Check all that apply)

*Referred by Child Protective Services

Yes
No

(A CPS Social Worker may refer children who are receiving CPS services and require child care as part of a CPS case plan)

APPLICANT'S EMPLOYMENT INFORMATION

1) Applicant's Employer Name

Phone/Ext

2) Applicant's Employer Name

(if more than one employer)

Phone/Ext

SECOND PARENT EMPLOYMENT INFORMATION

1) Second Parent's Employer Name

Phone/Ext

2) Second Parent's Employer Name

(if more than one employer)

Phone/Ext

APPLICANT'S SCHOOL/TRAINING INFORMATION

Applicant's School Name

Applicant's Total Units this Semester/Quarter

SECOND PARENT SCHOOL/TRAINING INFORMATION

Second Parent's School Name

Second Parent's Total Units this Semester/Quarter

INCOME INFORMATION

Are you currently on Cash Aid?

(if yes, please enter amount rec'd last month in Other Family Income below)

Yes
No

Have you ever been on Cash Aid in California?

Yes
No

If yes, most recent County of Cash Aid

Date Cash Aid ended

Enter your monthly income from all sources. Please note that all income will require verification prior to enrollment.

Regular Income - Applicant

Applicant's Employment Income

Applicant's Self-employment

Applicant's Unemployment

Applicant's Disability

Applicant's Child Support Received

Applicant's Spousal Support Received

Applicant's Other Income

Regular Income - Second Parent

Second Parent's Employment Income

Second Parent's Self-employment

Second Parent's Unemployment

Second Parent's Disability

Second Parent's Child Support Received

Second Parent's Spousal Support Received

Second Parent's Other Income

Other Family Income

Cash Aid (children only)

Cash Aid (family)

Foster Care

SSA (child)

SSA (parent)

SSI/SSP (child)

SSI/SSP (parent)

Income Adjustment - Applicant

Child Support Paid by Applicant

Income Adjustment - 2nd Parent

Child Support Paid by Second Parent

CHILD(REN) INFORMATION (enter information for each child in the household under age 21)

Child's Name

Last, First, Middle Initial

Date of Birth

Gender

M
F

Relationship to applicant

Natural/Adoptive/Stepchild
Foster
Guardianship
Grandchild

Name of Child Care Provider

Child's Name

Last, First, Middle Initial

Date of Birth

Gender

M
F

Relationship to applicant

Natural/Adoptive/Stepchild
Foster
Guardianship
Grandchild

Name of Child Care Provider

Child's Name

Last, First, Middle Initial

Date of Birth

Gender

M
F

Relationship to applicant

Natural/Adoptive/Stepchild
Foster
Guardianship
Grandchild

Name of Child Care Provider

Child's Name

Last, First, Middle Initial

Date of Birth

Gender

M
F

Relationship to applicant

Natural/Adoptive/Stepchild
Foster
Guardianship
Grandchild

Name of Child Care Provider

Please remember that this is only an application for subsidized child care. This application does not guarantee that you will receive services.

CERTIFICATION

I understand the information provided is needed to determine my eligibility for subsidized child care. I affirm that this information is correct.

Applicant Signature

Date