Child Care Payment Program Eligibility Application
Name of Parent/Guardian A
*
First Name
Last Name
Email
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Need for Child Care Services: Please select all that apply
*
Seeking Employment
Homeless (Seeking Permanent Housing)
CalWorksActivities (TANF)
Incapacity
Active with Child Protective Services (CPS)
Education/Training
Work
Name of Employer
Gross Monthly Income
Hours of work per week
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Is there another Parent/Guardian in the household?
*
Yes
No
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Name of Parent/Guardian B
*
First Name
Last Name
Email
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Need for Child Care Services: Please select all that apply
*
Seeking Employment
Homeless (Seeking Permanent Housing)
CalWorksActivities (TANF)
Incapacity
Active with Child Protective Services (CPS)
Education/Training
Work
Name of Employer
*
Gross Monthly Income
*
Hours of work per week
*
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Next
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your physical address the same as your mailing address?
*
Yes
No
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Please list the child(ren) residing in home under 18 years of age.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
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Name of Child Care Provider
Have you Received TANF in the last 24 months?
*
Yes
No
Is there any other income coming into your household?
*
Yes
No
What is the source of income?
What is the amount of other income per month?
Submit
Should be Empty: