CCTR Application

CONFIDENTIAL APPLICATION FOR CHILD DEVELOPMENT SERVICES AND CERTIFICATION OF ELIGIBILITY

Note: State regulations require a formal application and certification for child development services. You will receive written notice of your eligibility no later than 30 days from the date of your signature on this form. This form must be completed by an agency representative in consultation with the family. The agency must verify and certify family eligibility prior to beginning services. Refer to the attached instructions for the completion of this form.

Agency Name:(Required)

FRPM Site

Family Identification/Case No.:

Initial Subsidized Service Date:

Certification Period Date To Date:

Type of Application: (Check One)(Required)

Initial

Recertification

Pilot Program: (Check One)(Required)

Yes

Section I. Family Identification.

See Instructions, Section I.

If you are a single parent/caretaker, check this box:

Name of parent/caretaker (full name, including middle initial)

Phone no. (cell or home)

Phone no. (work/school)

Name of parent/caretaker (full name, including middle initial)

Phone no. (cell or home)

Address

Street Address City State ZIP Code

FIPS code

SECTION II. Family Eligibility and Reason for Needing Service

A. Family Eligibility Status (Check as many as apply.)(Required)

Protective Services or At-Risk

Current Aid Recipient

Income Eligible

Homeless

Programs for the Severely Handicapped

CSPP Only - Qualified FRPM Resident

Part-Day CSPP Only - Exceptional Need

Part-Day CSPP Only - Over-Income

Means-Tested Government Programs (See form CCD26A Instructions, Section II.)

B. Reason for Needing Service. Indicate all the reasons for needing care for each adult listed above. Enter “A” or “B” referring to parent/caretaker listed above. Attach documentation. (This section does not apply to part-day state preschool programs or programs for severely handicapped.)

Reason for Needing Service

Family is experiencing homelessness

Parent/caretaker is employed

Child(ren) is (are) recipient(s) of child protective services, or identified as being abused, neglected, or exploited or at risk thereof

Parent/caretaker is incapacitated

Parent/caretaker is enrolled in vocational training or educational program

Parent/caretaker is seeking employment

Family is seeking permanent housing

Stages 1, 2, and 3 CalWORKs recipients only

Stages 1, 2, and 3 CalWORKs recipients only

CalWORKs activities

Diversion

Date parent became ineligible for aid:

Date:

Record date of entry into each stage:

Stage 1:

Stage 2:

Stage 3:

Place checkmark below if applicable

CSPP Only - No Need Required

CSPP Only - FRPM Qualified Resident

C. Employment/Training Information. Must be completed for each adult listed in Section I above to document need on the basis of employment or training. (Attach documentation.)

Employer/School

Address

Street Address City State ZIP Code

Employer/School

Address

Street Address City State ZIP Code

Days and working/training hours:

From

Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Employer/School

Address

Street Address City State ZIP Code

Employer/School

Address

Street Address City State ZIP Code

Days and working/training hours:

From

Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

SECTION III. Family Adjusted Gross Monthly Income and Size

A. Family monthly income. The family’s adjusted monthly income from all sources

(Attach verification and documentation.):

B. Family income sources (Check all that apply. Do not count the gray shaded areas below) Black shaded boxes for CalWORKs recipients only.

NOTE: Section III B is for federal data collection purposes only.

Employment, including self-employment

Child support

Cash or other assistance under Title IV of the Social Security Act (TANF)

State-only alien and two-parent programs for CalWORKs recipients

Other federal cash income programs (such as SSI)

Housing voucher or cash assistance

Assistance under the Food Stamps Act of 1977

Other

Please specify:

C. Family size (See “Funding Terms and Conditions” for instructions on calculating family size.):

D. Parent(s) currently on active duty (i.e. serving full-time) in the U.S. Military?

Yes

E. Parent(s) a current member of a National Guard or Military Reserve Unit?

Yes

SECTION IV (A). Data on Children.

List all children residing in the home and counted in the family size.

Full Name of Child Including Middle Initial

Gender (M or F)

Birth Date

SECTION IV (B). Data on Children.

Complete only for children served by agency

Full Name of Child Including Middle Initial

Adjustment Factor Code

Ethnicity

Race

Language Code

Child is English Learner? (School age ONLY)

SECTION IV (C). Data on Children.

Complete only for children served by agency

(1) Full Name of Child Including Middle Initial

Provider/site Name

(8) Program Code

(9) Type of Care Code

(10) Hours of Care Per Day

(1) Full Name of Child Including Middle Initial

Provider/site Name

(8) Program Code

(9) Type of Care Code

(10) Hours of Care Per Day

(1) Full Name of Child Including Middle Initial

Provider/site Name

(8) Program Code

(9) Type of Care Code

(10) Hours of Care Per Day

(1) Full Name of Child Including Middle Initial

Provider/site Name

(8) Program Code

(9) Type of Care Code

(10) Hours of Care Per Day

SECTION V. Certification and Signature of Parent/Caretaker.

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Signature(Required)

Date(Required)

Relationship to Child:(Required)

Parent

Grandparent

Guardian

Foster Parent

Other:

Please describe(Required)

Signature

Date

Relationship to Child:

Parent

Grandparent

Guardian

Foster Parent

Other:

Please describe(Required)

Section VI. Family Fee.

(Refer to the current CDSS Family Fee Schedule.)

Type of Fee

Full-time

130 hours or more per month

Flat Monthly Fee Rate (See the instructions for Section VI.)

Flat Monthly Rate:

Specifics:

Type of Fee

Part-time

Under 130 hours per month

Flat Monthly Rate:

Specifics:

Section VII. For Office Use Only.

(Certification is not complete until eligibility is reviewed, signed, and dated by an agency representative.)

Eligibility Status:

Denied

Approved

Site Name:

Date Notice of Action Sent (Attach copy)

Date Notice of Action Given (Attach copy)

First Date of Subsidized Service

Last Date of Enrollment

Signature of Authorized Agency Representative

Title

Telephone no.

Date

Signature of Authorized Agency Representative

Title

Telephone no.

Date

This field is for validation purposes and should be left unchanged.

CCTR Application

CONFIDENTIAL APPLICATION FOR CHILD DEVELOPMENT SERVICES AND CERTIFICATION OF ELIGIBILITY

Section I. Family Identification.

SECTION II. Family Eligibility and Reason for Needing Service

SECTION III. Family Adjusted Gross Monthly Income and Size

SECTION IV (A). Data on Children.

SECTION IV (B). Data on Children.

SECTION IV (C). Data on Children.

SECTION V. Certification and Signature of Parent/Caretaker.

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Section VI. Family Fee.

Section VII. For Office Use Only.

El Cajon

El Cajon

El Cajon

Santee

Have Questions?

EL CAJON

Madison

EL CAJON

Prescott

EL CAJON

Second St., Preschool

SANTEE

Cottonwood Ave.