Family Identification

Parent/Caretaker Information (A)

Days and working/training hours

Parent/Caretaker Information (B)

Days and working/training hours

Family Eligibility and Reason for Needing Service

Family Eligibility Status (check all that apply):

Reason for Needing Service (check all that apply):
(full day enrollment only)

Family Adjusted Gross Monthly Income and Size

Certification and Signature of Parent/Caretaker

1. I understand that I am self-certifying single parent status under penalty of perjury in Section 1 of this document when the single parent/caretaker box has been checked.

2. I will notify the agency within 5 calendar days of any change in my family income, family size, or reason for needing child development services.

3. I understand that the information about my eligibility may be reviewed by representatives of the State of California, the federal government, independent auditors, or others as necessary for the administration of the program.

4. I understand that if the agency denies this application for services, I have the right to appeal.

5. I understand that I must renew my eligibility at least once a year or 3 months for at-risk. I further understand that if I do not renew my eligibility, I will no longer be eligible for subsidized child care services for my child.

6. I understand that I will receive a notice of approval or disapproval of my application within 30 days from the date I sign this form.

7. I understand that this certification is not complete until all documentation is submitted and this form has been reviewed, signed, and dated by an agency representative and signed and dated by me.

8. I certify that my family assets do not exceed $1,000,000; Child Care and Development Block Grant Act Section 658 P (4)(B).

I declare under penalty of perjury that the above information is true and correct to the best of my knowledge.