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Child Care Assistance Application Form

Before you fill out the Application below, please answer the following questions:

(Please note: If you answer “No” to any of the questions and a message does not pop-up, for Internet Explorer go to Tools in the navigation bar and activate the pop-up blocker for this site.)

(1)

Do you live in Dallas County, TX?

YesNo

(2)

Are you are a single parent household, (currently working and/or in job training or an educational program for a minimum of 25 total combined hours a week or more)?

YesNo

Are you a two-parent household, (who are BOTH currently working and/or in job training or an educational program for a minimum of 50 total combined hours a week or more)?

(3)

Do you meet the monthly income guidelines as outlined below (include ALL income received on a monthly basis, before taxes have been taken out)?

YesNo

# of Persons in Family	Total gross monthly income before taxes cannot be over ...
2	$2,246
3	$2,823
4	$3,399
5	$3,976
6	$4,553
7	$5,129
8	$5,706

If you answered YES to all 3 questions above, please fill out and submit the Application below.

Personal Information

First Name:
Last Name:
Mail Address:
Mail City:
Mail ZIP:
Phone Number:	(xxx-xxx-xxxx)
Cell Phone Number:	(xxx-xxx-xxxx)
Email Address:
Date of Birth:	(mm-dd-yyyy)
Last 4 digit of Social Security #:
Are you under Age 19:
Are you a Veteran:

Other Information

Marital Status:
If married Spouse Name: ng>If married Spouse Name:

Employment Information

Employer Name:
Number of Hours Worked:	(hh:mm)
Hourly Pay Rate:
Monthly Overtime, Commission, or incentive pay:

School and/or Training Information

Institution Name:
Hours:	&

Children Information ng"> Children Information

How many children in the household:
Child 1:
First Name:
Last Name:
Date of birth:	(mm-dd-yyyy)
Has a disability:	TrueFalse
Does this child need care?	YesNo
Child 2:
First Name:
Last Name:
Date of birth:	(mm-dd-yyyy)
Has a disability:	TrueFalse
Does this child need care?	YesNo
Child 3:
First Name:
Last Name
Date of birth:	(mm-dd-yyyy)
Has a disability:	TrueFalse
Does this child need care?	YesNo
Child 4:
First Name:
Last Name:
Date of birth:	(mm-dd-yyyy)
Has a disability:	TrueFalse
Does this child need care?	YesNo
Child 5:
First Name:
Last Name
Date of birth:	(mm-dd-yyyy)
Has a disability:	TrueFalse
Does this child need care?	YesNo
Child 6:
First Name:
Last Name:
Date of birth:	(mm-dd-yyyy)
Has a disability:	TrueFalse
Does this child need care?	YesNo