For Household Income Verification:

• Child Support Statements
• Foster Child Documentation
• Income Tax Form 1040 or 1040A
• SNAP, TANF, Adult OHP, OHP Bridge, OHP CWM
• ERDC, WIC (must show calculated household income on benefit letter or you will be asked to provide a different income method)
• Paystubs (3 most recent concurrent)
• SSI Letter
• Unemployment Statements
• 2024 W2
• Family Income Supplemental Form
• Other

For Child's Age Verfication:

• Copy of Birth Certificate
• Copy of Hospital Record
• Copy of Pediatrician/Doctor's Office Paperwork
• Child's Immunization Record (must be from healthcare organization)
• Health Insurance Documentation (must show birthday)
• Foster Care Placement Letter
• Legal Document (e.g benefits letter) that shows child's date of birth
• PSP Date of Birth Supplemental Form

*Please note that the document with footprints on it given by hospitals is not considered a birth certificate or legal document

For Residence in Oregon Verification:

• Current utility/service bill (electric, gas, water/sewer and waste)
• Lease or rental agreement
• Identification card or Oregon driver’s license
• Paystub, 1040 tax form, or W2
• Benefits letter (Social Security, TANF, SNAP, OHP letter, etc.) dated within the last 12 months
• Foster care placement letter
• Secure address through Address Confidentially Program
• PSP Address Supplemental Form

By signing this application, I confirm that I have given true and complete information, and I understand that the Oregon Department of Early Learning and Care may verify the information on this form. I understand that making false statements or intentionally omitting information may subject me to state and federal penalties. I understand PSP is a state funded program and preschool services provided under the PSP program may end if funds are no longer available.

I understand and agree that the information on this form, any information gathered or collected by the provider as part of the Certification of Eligibility, and any tests or reports, describing my child’s educational progress in the PSP Program may be shared with entities involved in the delivery of PSP services and supports to my child, including but not limited to preschool providers, Enrollment Committees, Hubs, Education Service Districts (Early Childhood Special Education services), Child Care Resource & Referral and the Oregon Department of Early Learning and Care, for the purpose of administering and evaluating the PSP Program.

Submission of this eligibility form is not a guarantee of admission into the PSP program.

Legal Parent/Guardian
Signature and Date Required