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Eligibility List Application

Current Address*:
City*:
State*:
Zip*:
Home Phone:
Cell Phone*:
Email*:
Relationship to child*:
Gross Monthly Income (Before Tax) List all sources of income under each parent.

Primary Parent

Primary Parent Name*:
Hours of work per week*:
Hourly wage*:
Employment (include self employment)*:
Cash Aid*:
Foster Payment*:
Unemployment*:
Disability Insurance*:
Other Income*:

Secondary Parent

Secondary Parent Name:
Hours of work per week:
Hourly wage:
Employment (include self employment):
Cash Aid:
Foster Payment:
Unemployment:
Disability Insurance:
Other Income:

List all children living in the home.

1.

Child Name*:
Child Date of Birth*:
Needing Care*:
Amount - Child Support Received*:

2.

Child Name:
Child Date of Birth:
Needing Care:
Amount - Child Support Received:

3.

Child Name:
Child Date of Birth:
Needing Care:
Amount - Child Support Received:

4.

Child Name:
Child Date of Birth:
Needing Care:
Amount - Child Support Received:

5.

Child Name:
Child Date of Birth:
Needing Care:
Amount - Child Support Received:
Have you received Cash Aid (Welfare/TANF/AFDC) within the last 2 years?*:
If "Yes", please provide a cash aid print out from the welfare department:
Do you have written referral from Child Protective Services (CPS) or At Risk?*:
If "Yes", please provide a letter:

By signing this application, you acknowledge and grant permission for your application to be shared among participating agencies. I declare that theaboveinformation is complete and true to the best of my knowledge. I understand my eligibility is based upon information given here and that documentation willberequired prior to enrollment. I understand that I will update this application every six months or my name will be removed from the list. I understandthatcomplete this application does not guarantee enrollment.
Agree*: