Complete With DocuSign GG WORKpdf GG EMERG

DocuSign Envelope ID: DB59455F-2537-4A0A-9C8B-88B554DAA732
CRYSTAL STAIRS, INC.

WRITTEN DISCLOSURE AND REQUEST FOR WRITTEN AUTHORIZATION TO
OBTAIN EMPLOYMENT AND/OR INCOME DATA FROM CONSUMER FORM
By signing below, I understand that Crystal Stairs, Inc. may obtain automated access to certain
employment and/or income data relating to me that is furnished by TALX Corporation, a provider
of Equifax Verification Services.
By signing below, I am providing my written authorization to Crystal Stairs, Inc. to obtain or

procure automated access to certain employment and/or income data relating to me that is
furnished by TALX Corporation, a provider of Equifax Verification Services.
By signing below, I acknowledge that I have read and understand everything above, that I
have the authority to give the permissions described above, and that I am signing below
voluntarily and agree to all information and permissions contained in this Crystal Stairs,
Inc. Written Disclosure and Request for Written Authorization to Obtain Employment
and/or Income Data from Consumer form.
Print Name: GRICEL GONZALEZ

Signature:
1/16/2024 | 11:15 PM PST
Date:
Crystal Stairs, Inc. Written Disclosure and Request for

Written Authorization to Obtain Employment and/or Income Data from Consumer (rev. 09.05.2017)
EMERGENCY AND IDENTIFICATION INFORMATION 400043292

501696099
(To be completed by parent or guardian & updated at re-certification & as changes occur.)
I.FAMILY INFORMATION
Parent Name: GRICEL GONZALEZ Telephone Number: (310) 487-7341 Family ID#: 172698
Home Address: 903 E 95TH ST City: LOS ANGELES State: CA Zip Code: 90002-1920
Spouse's Name: Spouse's Telephone:
Spouse's Business Address: City: State: Zip Code:
Do both biological parents live in home with the child(ren): YES NO
II. CHILD(REN) INFORMATION
Child 1: ROBERT ALFARO D.O.B 9/25/15 Child 2: EMILIA ALFARO D.O.B 8/20/18
Relation to Child: Parent Relative Non-Relative Relation to Child: Parent Relative Non-Relative
Child 3: LEONARDO ALFARO D.O.B 7/21/22 Child 4: D.O.B

Child 5: D.O.B Child 6: D.O.B

Child 7: D.O.B Child 8: D.O.B
III. NAMES OF PERSONS AUTHORIZED TO REMOVE CHILD(REN) FROM THE FACILITY / PROVIDER
(This child will not be allowed to leave with any other person without written authorization from parent or guardian.)
Name: N/A Telephone: N/A Relationship to child(ren): N/A
IV. PHYSICIANS TO BE CALLED IN AN EMERGENCY INFORMATION
Name of Hospital / Clinic: N/A Doctor's Name: N/A

Address: N/A Telephone Number: N/A
Do(es) child(ren) have Medical / Medi-cal Insurance: YES NO
City:
N/A State:N/A Zip Code:N/A If "yes", Medical /Medi-cal Insurance Number: N/A
If physician cannot be reached, what action should be taken? CALL 911/MOTHER

VI. ALLERGIES OR OTHER MEDICAL LIMITATIONS:
VII. PERMISSION FOR MEDICAL TREATMENT:

Administrative procedures vary among medical personnel and medical facilities with regard to provision of medical care for a child in the absence
of the parent. The exact procedure required by the physician or hospital to be used in emergencies should be verified in advance.
In case of an accident or an emergency, I authorize a staff member of the child development agency to take my child to the above-named
physician or to the nearest emergency hospital for such emergency treatment and measures as are deemed necessary for the safety and
protection of the child, at my expense.
Parent or Guardian Signature: Date: 1/16/2024 | 11:15 PM PST
[CDE_0012]Crystal Stairs • 5110 WEST GOLDLEAF CIRCLE, #150 • LOS ANGELES, CA 90056 • (323) 299-8998 • www.crystalstairs.org
Needs Assessment & Referral

400043292
500338918
Family Name: GRICEL GONZALEZ Family ID: 172698

Basic Family Needs Family Support Services
 Budgeting and Financial Planning  Parent Education
 Food Bank  Domestic Violence
 CalFresh  Legal
 Emergency Housing / Shelter  Immigration
 Other: ____________________________  Relative Caregiver (Kinship) Support
 Teen Support/Pregnancy
 Other: ____________________________
Child(ren) Health and Well-being Behavioral Health Services

 Positive Behavior / Guidance  Postpartum Depression
 Nutrition and Wellness  Counseling/Therapy (Individual/Family)
 Health Insurance / Immunizations  Depression / Anxiety
 Special Needs Services  Substance Abuse
 Bullying  Other: ____________________________
 Other: ____________________________
Career Development Advocacy

 Job Readiness  Know Your Rights
 Seeking Employment (Parent / Community Voices)
 Other: ____________________________  Other: ____________________________
Section 2:
Please complete this section:
Are you in need of Child Care Referrals?

 Yes, I am looking for a licensed provider to care for my child(ren)
 No, I do not need Child Care Referrals at this time
Would you like information on how to choose Quality Child Care for your child(ren)?
 Yes  No
Would you like to know more about our Parent Support Services Program?
 Yes  No  Maybe
Please provide your contact information and an R&R Program Specialist will contact you.
310-487-7341
Phone Number: _________________________ GRISCEL_GONZALEZ@YAHOO.COM
E-mail Address: _______________________________________
1/16/2024 | 11:15 PM PST

Parent Signature: _______________________________________________ Date: _____________________
Rev.042019
4000432925003
38918
[CDE_0018]Crystal Stairs • 5110 WEST GOLDLEAF CIRCLE, #150 • LOS ANGELES, CA 90056 • (323) 299-8998 •
www.crystalstairs.org
ACKNOWLEDGMENT OF RECEIPT OF
PARENT GUIDE
Improving the lives of families through child care

services, research, and advocacy
I have received a copy of the Crystal Stairs Parent Guide and agree that it is my responsibility to read
and understand the program rules, policies, and requirements it contains.
Parent/Legal Guardian
Print Name: GRICEL GONZALEZ
Signature: Date: 01/16/2024 _
Return this page to:
Crystal Stairs
5110 W. Goldleaf Circle
Suite 150
Los Angeles CA 90056-1282
Attn: CDSS Department
CDSS Case Management

Program Requirements Review
Updated January 2023 400043292
503829178
This document contains important information for your success as a program participant on the Alternative Payment Child
Care Program. Please read the information carefully, initial each line next to each statement and sign the form. If you have
questions, please contact your assigned Family Services Specialist.
RESPONSIBILITIES OF PROGRAM PARTICIPANTS
GG 1. Re-Certification: You are required to meet face-to-face with your Family Services Specialist (FSS) after the end of your
certification period to recertify your childcare services. If your case is in the Stage 2 or Stage 3 programs, you must
recertify after 12-months. If your case is in the CAPP Program, you must recertify after 24 months. You will be required
to provide documents that confirm your current income and eligibility for each adult counted in your family size. It is
important that you attend this meeting and submit the required documents requested to avoid possible termination of
your child care services. Failure to complete the recertification process within 50 days after your previous certification
period ends may result in dis-enrollment from the program.
GG 2. Fraud Policy: If you Intentionally submit false or misleading information in order to access services from any Crystal
Stairs program, your services will be terminated and you will face legal action. You will be required to repay the costs of
child care and development services fraudulently received.
GG 3. Documenting Family Size: You must submit documentation for all the individuals counted in the family size who reside
in the household of the children receiving child care services. If you report that you are a single parent/caretaker, you
will be required to self-certify the absence of the second parent under penalty of perjury.
GG 4. Reporting Changes: Once you are approved for services during enrollment/recertification, your are not required to
submit eligibility or need information unless it is voluntary, or you need to change your child care provider. You must
also report, within thirty (30) calendar days, when your monthly income exceeds 85 percent of the State Median
Income (SMI). You may voluntarily report changes if you need to reduce or eliminate your family fee (due to a decrease
in income or an addition to your family size) and/or if you need more child care hours.
It is important for your Family Services Specialist to be able to reach you by mail, email, and telephone as needed. If
these changes are not reported, your child care services may be terminated.
GG 5. Family Fees: If your family’s total countable income is within the determined State Median Income percentile, you may
be required to pay a share of your child care costs. This share of cost is called a “Family Fee”. Family fees are based on
your gross monthly income and your family size. If you are required to pay a fee, all fees must be paid directly to your
provider the 1st of each month and in the full amount. You and your provider must indicate on the Attendance Record
that all fees were paid in full for the month or your Attendance Record must state that you and your child care provider
have entered into a mutually agreed upon payment plan. If you do not pay your fees, your child care services will be
terminated and may not re-enroll for services until the delinquent fee balance has been paid. Family Fees have been
waived through June 30, 2023.
GG 6. Attendance Record: Each day you drop off and pick up your child for child care services, you or your authorized
representative must record your time in and time out. The Attendance Record must be accurately maintained on a daily
basis. If you do not fill out or sign the Attendance Record correctly and on time or refuse to sign the Attendance
Records, your child care services may be terminated.
Abandonment of Care: If you stop using child care services and/or have not been in contact with your provider for at
least seven (7) consecutive calendar days, your Provider is required to report this to Crystal Stairs as abandonment of
care. Once reported, your FSS will attempt to contact you and send you a notification by mail. Your child care services
will be terminated for abandonment of care if you do not establish contact with your provider or your FSS.
GG 7. Authorized Child Care Schedule: The days and hours for your child care are determined by your need activity and any
applicable travel, study, or sleep time for parents that work certain graveyard shifts. If your need changes and you need
additional time or days, you must request a change in advance and provide documentation of the additional need. Your
Provider will not be reimbursed for child care that is not authorized with a Certificate of Enrollment.
GG 8. Reimbursement Limited to One Provider: Except for reimbursement for child care provider days of non-operation and
alternate child care providers, Crystal Stairs, Inc. will reimburse only one provider of services per child when the hours
of operation of the provider selected by the parents can accommodate the certified need for services. Crystal Stairs,
Inc. may choose to reimburse more than one provider per child when the hours of operation of the provider cannot
accommodate the certified need for child care.
GG 9. Requesting a Licensed or a License-Exempt Provider without a valid agreement: When you request child care with a
provider that does not have a valid agreement, all required documents must be submitted and approved by the due
date before Crystal Stairs starts paying for your child care services. If the agreement is not complete and/or does not
meet all the requirements by the deadline, you will be asked to select another provider and the time period will not be
reimbursed for providers that do not have an active provider agreement (this depends on your provider submitting all
required documents by the due date).
Parent Maximum Subsidy Certificate Form: When your services have been approved, you will receive a Parent
Maximum Subsidy Certificate indicating the child care provider you have selected, your child’s information, the
approved child care services schedule and the maximum reimbursement for your child care schedule. If your child care
provider charges fees in excess of this amount, you are financially responsible for paying those fees to your child care
provider. If you have questions about your subsidy amount, please contact your Family Services Specialist for more
information.
Child Care Provider Rules and Responsibilities: Parents are required to adhere to the child care provider’s rules and
requirements in addition to Crystal Stairs Program rules. Parents must carefully review all child care provider
agreements/contracts that are completed between the child care provider and the parent and understand any
additional fees or charges before completing enrollment with any child care provider.
GG 10. Student Agreement Policy (if applicable) You must provide your FSS with documentation to support your approval for
the Educational/Training Program. It must include the days and hours of enrollment, the name of the institutions
providing the instruction, your current class schedule details, syllabus, registration confirmation, and a signature or
stamp of the training institution’s registrar. Your FSS will determine the days and hours needed per week based on the
documentation provided. Child care will only be provided when you are enrolled and participating in your approved
educational program, and services will be limited to six (6) years from the initiation of services or 24 semester units
after attaining a Bachelor’s degree.
Recertification: To continue yearly educational program services, you must provide documentation that shows you
have made adequate progress in your program. If you have not made adequate progress, you will be placed on
academic probation for your next certified period of services. If you have not made adequate progress during the
academic probation period and do not have any other need for services, you may be dis-enrolled from the program,
and will not be able to apply for services again until after 6 months following the termination.
GG 11. Important Agency Policy: Using disrespectful language (written or verbal), posing any type of threats (specific or
implied), vandalizing property, demonstrating verbal or physical abuse, or endangering the life of any child, parent,
child care provider, or Crystal Stairs, Inc. staff member will result in termination of your child care services. This type of
behavior is not acceptable and will not be tolerated. Legal action may be taken, if necessary.
I understand the above stated requirements. I understand the above includes only a summary of the program requirements of
Crystal Stairs, Inc. for more detailed information, I will read the Parent Handbook.
1/16/2024 | 11:15 PM PST
GRICEL GONZALEZ (172698)
Participant Name Participant Signature Date
CDSS Case Management

Child Care Provider Request 400043292
503490103
Parent Information
Parent Name: GRISCEL GONZALEZ Family ID #: 172698 Phone #: 310-487-7341
Address: 903 E. 95TH ST City: LOS ANGELES Zip Code: 90002
Provider Request Type
New Provider Change Provider Add Vacation Care Provider Add Evening/Weekend Provider
Start date: Start date: Start date: Start date:
If changing provider, Current Provider: Last day of care:

Important Note: All changes requested must be approved by your specialist prior to beginning services.
Child(ren)
The change being requested is for the following child(ren):
1) ROBERT ALFARO DOB: 9/25/15 4) DOB:
2) EMILIA ALFARO DOB: 8/20/18 5) DOB:
3) LEONARDO ALFARO DOB: 7/21/22 6) DOB:
New Provider Information
Provider Name: MARIA T. ORTIZ Provider ID #: 230496 Phone #: 310-462-6579
Address: 3243 E. 108TH ST City: INGLEWOOD Zip Code: 90303
If center, Contact Person: Alternate Phone #: ____________ E-Mail Address: MA.ORTIZ96@GMAIL.COM
__________________________
Provider Type
Licensed Provider Facility Type: Center Home
1. Is this provider licensed to care for your child(ren) age?............................................................... YES NO
2. Will this provider exceed their maximum capacity by caring for your child(ren)? ........................ YES NO
3. Does this provider have an agreement with Crystal Stairs, inc.?................................................... YES NO
License-Exempt Provider Relationship to the child (select one):
(Provider does not have a license to provide
Relative (select one)................................. Grandparent Aunt Uncle
child care services)
Non-Relative (select one)....... Friend Neighbor Other:
1. If you selected “Non-Relative”, is the provider providing care for other “Non-Relative” child(ren)
with Crystals Stairs?....................................................................................................... YES NO
2. Is the provider 18 years of age or older? ....................................................................................... YES NO
3. Does the provider have a valid Social Security Number to work in the U.S.? ............................... YES NO
4. Where will child care services be provided? Provider’s Home Child(ren) Home*
Interim Care
If selecting a provider that does not have an eligible agreement with Crystal Stairs, will you like information on accessing
Temporary (Interim) Care until your provider’s agreement is approved? ..... YES NO
I understand that I need prior approval before I can start child care services with any provider I select and that Crystal Stairs will
not pay for child care that has not been approved by my Family Services Specialist.
1/16/2024 | 11:15 PM PST
Parent/Guardian Signature: Date:
For Office Use Only

New Provider Agreement
NO YES, PV Agreement #: Date Requested:
Required?
CDE Case Management

Consent to Release Information 400043292
503195087
I, GRICEL GONZALEZ, give permission for Crystal Stairs, Inc., to verify any information utilized to determine my family
eligibility during the time that I am enrolled in the subsidized child care program.
I authorize the sharing of information between agencies to verify my income, eligibility, and need for child care and/or
support services. Agencies that may be contacted include, but are not limited to, the Department of Public Social
Services, Department of Child Support Services, training sites/schools, social service agencies, referring physicians,
emergency shelters, and employers.
I give my permission for Crystal Stairs, Inc., to request from and/or provide to other publicly funded agencies any
eligibility information needed to ensure proper use of State/Federal funds.
I understand that if my family is found to be ineligible for child development services, or, if the information provided
to Crystal Stairs, Inc., during the time my family is enrolled is found to be inaccurate, I will be responsible for
repayment to Crystal Stairs, Inc., for child care payments paid to my provider(s).
GRICEL GONZALEZ X
Print Name Signature
Biological Mother 1/16/2024 | 11:15 PM PST

Relationship to child(ren) Date
School Track and Verification Form

400043292
501674784
This form must be completed for all children 5 years of age and older that currently attend school, or will be attending
school in the upcoming school year including Kindergarten. Parents must attach school calendar copies.
Parent/Guardian Name: GRICEL GONZALEZ Family ID#: 172698
Child Name: ROBERT ALFARO Child Age: 8 Child Grade: 2

2023-2024 Lennox School District
School Year: School District:
Jefferson Elementary School
School Name: School Track: ☐ Traditional ☐Other:_______________
School Address: 10322 Condon Ave. Lennox CA 90304
Monday Tuesday Wednesday Thursday Friday

Academic 8:15-2:52 8:15-2:52
8:15-2:52 8:15-2:52 8:15-2:52
Schedule: - - - - -
School Phone: 310-680-5650

School Type: ☐Public ☐Private ☐Charter
Child’s School Start Date: 08/16/2023
Child Name: EMILIA ALFARO Child Age: 5 Child Grade: K
School Year: 2023-2024 School District: Lennox School District

Jefferson Elementary School
School Address: 10322 Condon Ave. Lennox CA 90304

Academic 8:15-2:52 8:15-2:52 8:15-2:52
8:15-2:52 8:15-2:52
Schedule: - - - - -
School Phone: 310-680-5650

School Type: ☐Public ☐Private ☐Charter
Child’s School Start Date: 08/16/2023
Child Name: Child Age: Child Grade:
School Year: School District:

School Address:

Academic
Schedule: - - - - -
School Type: ☐Public ☐Private ☐Charter School Phone:
Child’s School Start Date:
I certify under the penalty of perjury that the information stated above is true and correct to the best of my knowledge.
Parent Signature: Date 1/16/2024 | 11:15 PM PST
Self-Certification of Income Form

400043292
500521803
When no other documentation is available, this form is used to document income. Please record undocumented employment
income, non-employment income and periods of zero income.
Family Name: GRISCEL GONZALEZ Family ID#: 172698
EMPLOYMENT INCOME AND EMPLOYMENT INFORMATION SELF-CERTIFICATION

Job Title: Date of Hire: ___/___/___
Employer Name and Address: ______
Description of Employment/Type of Work Performed____________________________________________________________
I have no paystubs, receipts, or other documentation of employment and: (PLEASE CHECK ONE)
☐ My employer has been unresponsive or refused to provide Subsidized Programs Employment Verification Form.
☐ A request for employment verification would adversely affect my employment status.
☐ Crystal Stairs is unable to verify my employment through an independent entity. Other: _________________________________
My position is: ☐ Permanent ☐ Temporary Assignment: Begin: / / Ends: / /_____

I am paid by: ☐ Payroll Check ‌☐ ‌ Personal/Business Check ☐ Cash
My pay rate is: ☐‌ $ /Hour ☐‌ $ /Day ‌☐$ /Week ☐$ /Month
Pay Frequency: ‌☐‌ Weekly ☐ Every 2 Weeks ☐ Twice a Month ☐ Monthly
I have the potential to work overtime: ☐ Yes ☐ No I am paid lunch: ☐ Yes ☐ No Length________
My income for the preceding month was: $______
☐ I WORK A SET SCHEDULE:

Start Time A.M. P.M. End Time A.M. P.M.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
☐ I WORK A VARIABLE SCHEDULE (PLEASE CHECK ONE): ☐ Days Vary ☐ Hours Vary ☐ Days and Hours Vary
 The number of hours per week range from hours to hours.
 The earliest time I can start working is am/pm and the latest I can stop working is am/pm.
 The average number of days I can work per week is .
OPTION 1: TOTAL INCOME FOR THE PRECEDING 12 MONTHS

Income Amount: $ 50,228.43
OPTION 2: SELF DECLARATION OF AFFIDAVIT STATEMENT CHECK-MARKED BY APPLICANT

My Income Fluctuates.
My Income Does Not Fluctuate.
4000432925005
21803
OPTION 3: NON-EMPLOYMENT INCOME SELF-CERTIFICATION

Type of Income: Income Amount:$
Purpose for Income: Income Frequency:
OPTION 4: ZERO INCOME SELF-CERTIFICATION

Zero Income Start Date: ___/___/___ Zero Income End Date: ___/___/___
How is your family supported with zero income?:
I hereby certify under penalty of perjury under the laws of the State of California that the information stated above and any
documentation submitted herewith, are true and correct to the best of my knowledge, and that none of such information or
documentation is misleading, untrue, or false. I further understand and acknowledge that by signing this statement, the
above information and documentation submitted herewith are subject to verification and hereby grant Crystal Stairs, Inc.
the authority to verify such information and documentation. If the above information and/or documentation submitted
herewith are found to be false, untrue or misleading, I understand that I may be subject to prosecution and punishment
under the laws of the state of California.
Griscel Gonzalez 1/16/2024 | 11:1

Print Name Signature Date _
FOR OFFICE USE ONLY
1ST Verification attempt via ☐ Phone Call: /Date ☐ Fax: /Date ☐ Email: /Date
2nd Verification attempt via ☐ Phone Call: /Date ☐ Fax: /Date ☐ Email: /Date
☐ I certify that above information provided by the parents is correct to the best of my knowledge, supports the reported
income, and is reliable and consistent with all other family information and this type of employment. I attest to the
reasonableness of the days and hours of employment based on the description of the employment and community
practice.
☐ I certify that the information provided is not consistent with community practice and child care need has not been
established by the parent, therefore no care been authorized.
☐ I certify that the information provided is not consistent with community practice and child care has not been authorized
by the parent, therefore the following care has been authorized:___________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Specialist Name_______________________________ Specialist Signature______________________________ Date__________
CDE Case Management
Attendance Record Checklist
Parent Name (First Initial, Last Name): GRICEL GONZALEZ ________________________________

Date: ______________
Specialist:
REVIEW EACH ITEM WITH PARENT AND MARK THE BOX WHEN COMPLETE
1. Did Specialist review the need schedules with the parent?
2. Did Specialist review the child care schedule for each child with the parent?
3. Did Specialist review how the “How to Complete an Attendance Record” flyer with parent?
a. Missing time in/out

b. Time In/Out on provider’s non-operational day/holiday (indicates attendance is not
being recorded daily by parent/authorized representative
c. Not accurately recording arrival time/pick up time (block claiming)
d. Making Corrections on AR (crossing out mistakes, whiteout, etc.)
e. Not completing Family Fee Cert & Receipt Section
f. Not completing parent and provider Attendance Certification Section on bottom of AR

g. For varied schedules, using child care that is broadly inconsistent with the
current authorization
h. How to voluntarily report changes if schedule updates are needed
i. Provider is not recording time In/Out for school age children
I have been explained and understand my responsibilities when completing Attendance Records. If I do not use
my child care services accurately, or if I do not complete the Attendance Records accurately on a consistent
basis, I do understand that I must attend a mandatory orientation. Continued failure to use accurate child care
services or to complete Attendance Records accurately could result in termination of my child care services.
Parent Signature:
1/16/2024 | 11:15 PM PST
Date: ________
Specialist Initials: ___
Crystal Stairs, Inc. • 5110 West Goldleaf Circle #150 • Los Angeles, CA 90056 • (323) 299-8998 • www.crystalstairs.org
Confidential Application for Agency Name: Crystal Stairs

Child Development Services and Family Identification/Case No.: 172698
Certification of Eligibility Initial Subsidized Service Date: 4000432925
Form 9600 Page 1, (REV 3/23) Type of Application: (Check one) Initial Recertification 00064410
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.
Section I. Family Identification. If you are a single parent/caretaker, check this box: See Instructions, Section I.
Name of parent/caretaker (full name, including middle initial) Phone no. (cell or home) Phone no. (work/school)
A. GRICEL GONZALEZ (310) 487-7341 (310) 680-3500
Name of parent/caretaker (full name, including middle initial) Phone no. (cell or home) Phone no. (work/school)
B.
Street address City State Zip FIPS code
903 E 95TH ST LOS ANGELES CA 90002-1920 06037
Section II. Family Eligibility and Reason for Needing Service
A. Family Eligibility Status (Check as many as apply.)
Protective services Current Aid Recipient Income eligible Homeless Programs for the
severely
Means-Tested Head Start/ handicapped
Government Program Early Head Start
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.)
Parent/ Parent/
Parent/
Caretaker
Reason for Needing Service Caretaker Reason for Needing Service Caretaker Stages 1, 2, and 3 CalWORKs recipients only
Homeless Education or training CalWORKs activities

Date parent became
ineligible for aid:
A Working Actively seeking employment Diversion
Date:
Child referred for protective services because of Seeking permanent housing Record date of entry into each stage:
neglect, abuse, exploitation, or risk thereof Stage 1: Stage 2: Stage 3:
Parent/caretaker incapacitated because of medical or

psychiatric special needs
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.)
Parent/
Caretaker Employer/School Street Address City Zip
A LENNOX PRESCHOOL 10203 FIRMONA AVE INGLEWOOD 90304
Days and working/ From: Mon. Tues. Wed. Thurs. Fri. Sat. Sun.
To:
training hours: 7:30AM-4:30PM 7:30AM-4:30PM 7:30AM-4:30PM 7:30AM-4:30PM 7:30AM-4:30PM
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.): $ 4185.70
B. Family income sources (Check all that apply. Do not count the gray shaded areas in Section III. A above.) Black shaded boxes for CalWORKs recipients only.
NOTE: Section III B is for federal data collection purposes only.
Employment, including self-employment Other federal cash income programs (such as SSI)
Child support Housing voucher or cash assistance
Cash or other assistance under Title IV of the Social Security Act (TANF) Assistance under the Food Stamps Act of 1977
State-only alien and two-parent programs for CalWORKs recipients Other

C. Family size (See “Funding Terms and Conditions” for instructions on calculating family size.): 4
D. Parent(s) currently on active duty (i.e. serving full-time) in the U.S. Military? YES NO
Parent(s) a current member of a National Guard or Military Reserve Unit? YES NO
[CDE_0044]Crystal Stairs • 5110 WEST GOLDLEAF CIRCLE, #150 • LOS ANGELES, CA 90056 • (323) 299-8998 • www.crystalstairs.org Page: 1/2
Confidential Application for
Child Development Services and
Certification of Eligibility
Form 9600 Page 3 (REV. 3/23) 4000432925
00064410
Section IV. Data on Children. List ALL children residing in the home and counted in the family size.
Complete for all children residing in the home Complete only for children served by your agency For children enrolled in more than one program or site, use additional lines as needed
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
Full Name Gender Birth Date Adjustment Native Hours of Care per Day
of Child Factor Language Program Type of Care
Code Code Code
Including Middle M F Child is
English
Ethnicity
Initial
Race
MM/DD/YYYY Lan- Learner?
guage (School age
Code ONLY) M T W TH F SAT SUN
00 N
S
EMILIA ALFARO 08/20/2018 Provider/site name:
V
21 00 N
S
LEONARDO ALFARO 07/21/2022 Provider/site name:
V
00 N
S
ROBERT ALFARO 09/25/2015 Provider/site name:
V
Section V. Certification and Signature of Parent/Caretaker.

1. I understand that I am self-certifying single parent status under penalty of 5. I understand that this certification is not complete until all
perjury in Section 1 of this document when the single parent/caretaker box has documentation is submitted and this form has been signed and dated by
been checked. Parent Initials: ____________ me and reviewed, signed, and dated by an agency representative.
2. I understand that the information about my eligibility may be reviewed by 6. I certify that my family assets do not exceed $1,000,000; Child Care
representatives of the State of California, the federal government, independent and Development Block Grant Act Section 658 p (4)(B).
auditors, or others as necessary for the administration of the program.
7. I understand that I must renew my eligibility at least once a year. I
3. I understand that if the agency denies this application for services, I have
further understand that if I do not renew my eligibility, I will no longer
the right to appeal.
be eligible for subsidized child care services for my child.
4. I understand that I will receive a notice of approval or disapproval of my
application within 30 days from the date I sign this form.
I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature Date Relationship to Child: Parent Grandparent Guardian
1/16/2024 | 11:15 PM PST
Foster Parent Other: Please describe
Signature Date Relationship to Child: Parent Grandparent Guardian
Foster Parent Other: Please describe
Section VI. Family Fee (Refer to the current CDE Family Fee Schedule).
Type of Fee Flat Monthly Fee Rate (See the instructions for Section VI.)
Full-time
Flat Monthly Rate: $ 0.00 Specifics:
130 hours or more per month
Part-time
Flat Monthly Rate: $ 0.00 Specifics:
Under 130 hours per month
Section VII. For Office Use Only. (Certification is not complete until eligibility is reviewed, signed, and dated by an agency representative.)
Date Notice of Action Sent Date Notice of Action Given First date of subsidized service Last date of enrollment
Eligibility Status Accepted Denied (Attach copy) (Attach copy)
Signature of Authorized Agency Representative Title Telephone number Date

Quality Assurance Program (323) 421-1309
Specialist
Signature of Supervisor (Optional) Title Telephone number Date
CDE Case Management 400043292
Income Worksheet 500662928
Total Family Monthly Countable Income (Show all countable income types at all times, even if zero)(pt A&B income combined)
Family Name/ID: GRICEL GONZALEZ / 172698 Calculate Date: 01/16/2024

Flat Monthly Family Fee : Part Time N/A Full Time N/A Effective Date: 01/01/2024
Wages or salaries GRICEL GONZALEZ $ 0.00 Wages from migrate, agriculture, or seasonal work $ 0.00
Profit from self-employment $ 0.00 Spousal support $ 0.00
Survivor or retirement benefits $ 0.00 Dividends, interest, rental $ 0.00
Rent for room within the family's residence $ 0.00 Allowance for housing or automobiles $ 0.00
Inheritance $ 0.00 Net proceeds from the sale of real property $ 0.00
Alimony $ 0.00 TANF cash grant $ 0.00
Social Security $ 0.00 Unemployment benefits $ 0.00
Worker's compensation $ 0.00 Disability insurance $ 0.00
Pensions and annuities $ 0.00 Insurance on court settlements $ 0.00
Veteran's pensions $ 0.00 YOUAKIM $ 0.00
Grants/loans and financial aid for student parents $ 0.00 Year-end salary adjustments/bonuses $ 0.00
Benefits such as medical, dental, insurance $ 0.00 Money earned from work study $ 0.00
Migration $ 0.00 Child Support Paid to Parent $ 0.00
Other $ 4185.70 $
Total Family Monthly Income Uncountable
Foster care grants payments or clothing allowance 0.00 No Cash Value Benefits such as medical, insurance 0.00
Food stamps (CalFresh) 0.00 Housing vouchers 0.00
Personal loans 0.00 Tax refunds or rebate checks 0.00
Earnings of children under 18 years of age 0.00 Allowances received for uniforms or other 0.00
SSI/SSP 0.00 School grants/loans/financial aid 0.00
Other Not Countable 0.00

Total Family Monthly Income Deductions
Business expenses for the self-employed -$0.00 Child support paid by the parent(s) on the program -$0.00
Total Adjusted Family Monthly Income $4185.70
Completed By Date
Verified By Date
400043292
500662928
INCOME CALCULATION
Employment Income Description Pay Average Calculation Pay Avg Adjustment Monthly
Income Period Schedule Date Pay Amount Income
GRICEL GONZALEZ LENNOX PRESCHOOL Twice a 12/05/2023 $0.00 10 Months

$ 0.00 $0.00 $0.00
01/16/2024 - Pay Check Month 12/20/2023 $0.00 Fluctuate
You must report changes in your income, within 30 days, when your income exceeds 85% of State Median
Income (SMI) as indicated below:
Family Size 4 85% SMI $8025.000
I hereby certify under penalty of perjury under the laws of the State of California that the information stated above
and any documents submitted herewith, are true and correct to the best of my knowledge, and that none of such
information or documentation is misleading, untrue or false. I further understand and acknowledge that by signing this
statement, the above information and submitted documents herewith are subject to verification and herby grant
Crystal Stairs, Inc. the authority to verify such information and documents. If the above information and/or documents
submitted herewith are found to be false, untrue or misleading, I understand that I may be subject to prosecution and
punishment under the laws of the State of California.
1/16/2024 | 11:15 PM PST
Participant Signature Date

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DocuSign Envelope ID: DB59455F-2537-4A0A-9C8B-88B554DAA732

CRYSTAL STAIRS, INC.

By signing below, I am providing my written authorization to Crystal Stairs, Inc. to obtain or

Print Name: GRICEL GONZALEZ

Crystal Stairs, Inc. Written Disclosure and Request for

EMERGENCY AND IDENTIFICATION INFORMATION 400043292

Child 3: LEONARDO ALFARO D.O.B 7/21/22 Child 4: D.O.B

Child 5: D.O.B Child 6: D.O.B

Child 7: D.O.B Child 8: D.O.B

Name of Hospital / Clinic: N/A Doctor's Name: N/A

If physician cannot be reached, what action should be taken? CALL 911/MOTHER

VII. PERMISSION FOR MEDICAL TREATMENT:

Parent or Guardian Signature: Date: 1/16/2024 | 11:15 PM PST

Needs Assessment & Referral

Family Name: GRICEL GONZALEZ Family ID: 172698

Child(ren) Health and Well-being Behavioral Health Services

Career Development Advocacy

Are you in need of Child Care Referrals?

1/16/2024 | 11:15 PM PST

Improving the lives of families through child care

Print Name: GRICEL GONZALEZ

Signature: Date: 01/16/2024 _

Return this page to:

CDSS Case Management

RESPONSIBILITIES OF PROGRAM PARTICIPANTS

CDSS Case Management

If changing provider, Current Provider: Last day of care:

For Office Use Only

CDE Case Management

Biological Mother 1/16/2024 | 11:15 PM PST

School Track and Verification Form

Child Name: ROBERT ALFARO Child Age: 8 Child Grade: 2

Monday Tuesday Wednesday Thursday Friday

School Phone: 310-680-5650

Child Name: EMILIA ALFARO Child Age: 5 Child Grade: K

School Year: 2023-2024 School District: Lennox School District

Monday Tuesday Wednesday Thursday Friday

School Phone: 310-680-5650

Child Name: Child Age: Child Grade:

School Year: School District:

School Name: School Track: ☐ Traditional ☐Other:_______________

Monday Tuesday Wednesday Thursday Friday

School Type: ☐Public ☐Private ☐Charter School Phone:

Child’s School Start Date:

Self-Certification of Income Form

EMPLOYMENT INCOME AND EMPLOYMENT INFORMATION SELF-CERTIFICATION

☐ A request for employment verification would adversely affect my employment status.

My position is: ☐ Permanent ☐ Temporary Assignment: Begin: / / Ends: / /_____

My pay rate is: ☐‌ $ /Hour ☐‌ $ /Day ‌☐$ /Week ☐$ /Month

Pay Frequency: ‌☐‌ Weekly ☐ Every 2 Weeks ☐ Twice a Month ☐ Monthly

My income for the preceding month was: $______

☐ I WORK A SET SCHEDULE:

OPTION 1: TOTAL INCOME FOR THE PRECEDING 12 MONTHS

OPTION 2: SELF DECLARATION OF AFFIDAVIT STATEMENT CHECK-MARKED BY APPLICANT

OPTION 3: NON-EMPLOYMENT INCOME SELF-CERTIFICATION

OPTION 4: ZERO INCOME SELF-CERTIFICATION

Griscel Gonzalez 1/16/2024 | 11:1

FOR OFFICE USE ONLY

Specialist Name_______________________________ Specialist Signature______________________________ Date__________

CDE Case Management

Attendance Record Checklist

Parent Name (First Initial, Last Name): GRICEL GONZALEZ ________________________________

1. Did Specialist review the need schedules with the parent?

a. Missing time in/out

Specialist Name___________ Specialist Signature Date