Affordable Child Care Assistance Application
Apply to determine your eligibility for state-supported child care assistance. Please complete all sections with accurate information.
Parent's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employment Status
*
Employed Full-Time
Employed Part-Time
Unemployed
Self-Employed
Student
Other
Employment History (Past 3 Years)
*
Do you pay mortgage or rent?
*
Mortgage
Rent
Neither
Monthly Mortgage or Rent Payment (USD)
*
Yearly Household Income (USD)
*
Upload Previous Year's Tax Return
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Application
Should be Empty: