NJ CHILD CARE SUBSIDY PROGRAM Documentation Checklist Below is a general lst of required documents for each section ofthe Child Care Subsidy Program Application that must be submitted for intial eligibity consideration. Additional document's may also be required based on program requirements, Please contact and check with the Child Care Resource and Referral Agency (CCR&R) if you have questions or need assistance. You can reach your local CCRAR at 1-800-332-9227 or by visiting www.ChildCareNJ.gov. ys eae We) For each applicant/co-applicant, submit one of the documents from Column A. If you are unable to provide from Column A, you may submit two documents from Column B: COLUMN A (PRIMARY DOCUMENTATION) COLUMN B (SECONDARY DOCUMENTATION) Submit one: OR Submit twos (Driver's License (2) High School Diploma, GED, or Callege Diploma. [1 Goverment Issued Photo ID Card [Health Insurance Card ot Prescription Card | Co) Military Photo I Card (Printed Paystub [Employer Issued Photo 1D | E)pith Certticate (epplicantico-applicant or child's) | [School Photo ID [Passport [ [Permanent Resident Card (Green Card) By For any applicentico-applicant, submit one ofthe following to verify residence Ci Social Security Card (1 Current Rental/Lease Agreement or Mortgage Bill [Home utility bills [1 Court decree (if applicable) (C) Medical documentation [School records showing residence [Z] Vehicle Registration or Title or NJ Driver's License (Co Custody Agreement or other court documents for (C1 Most recent filed tax forms showing dependency. ‘guardianship (For dependents 18+, must provide fled IRS 1040 Forrn) ‘if you or your cild are homeless and do not have a fixed address, ploase contact your CORSR for assistance, RELATIONSHIP AND HOUSEHOLD SIZE For any child in need of child care services, submit the following to prove relationship: (child's Birth Cortiticate [1 Court decree (if applicable) [5] Custody Agreement or other court documents for guardianship (if applicable) For each dependent residing in the home and included inthe fariy size, submit one ofthe folowing to verify family size: (Birth Certificate (C1 Court decree (if applicable) (2 Custody Agreement or other court documents for C1 Most recent fled tax forms showing dependency guardianship (f applicable) (For dependents 18+, must provide filed IRS 1040 Form)NJ CHILD CARE SUBSIDY PROGRAM Documentation Checklist Continued CEASA ele ea hoes | For any cl | Clu:s. pith Certinoate | Ci ceantate oF cizenship | JUSS, Passport or Passport Card | social Security Card in need of care, submit one of the following: INCOME FROM EMPLOYMENT: | C2] Must provide current one month's worth of current pay stubs (€.g. 4 weeldy, 2 biweekly, ete.) | NEW EMPLOYMENT ONLY: Ifpaystubs are not available | [5 Employer letter on company letterhead (signedidated) Must include rate of pay, hours worked per week, employer contact information, and fist date of employment; or [C1DFD “Verification of Employment” Form If approved for subsidy, applicant/co-applicant will be required to follow up with pay stubs. [SELF-EMPLOYED ONLY: Submit Current IRS Tax Transcript of Form 1040 Schedule C, *Profit or Loss from Business” [TUNABLE TO WORK or INCAPACITATED: DFD “Parent Incapacitaion Verifcation” Form SCHOOL/TRAINING For each applicantloo-applicant, submit one of the following: [1 SCHOOL: Detailed school schedule naming the school and the student, including days and hours attending, crecits, start and end date data and weekly schedule CITRAINING PROGRAM: Lettor on Program letterhead (signedidated) indicating name of program, start and end [7] Permanent Resident Card (Green Card) [-] Uscis Form F651 (Allen Registration Card) (Refugee Travel Document (Form |-571) [UscisiiNs Form -84 stamped "Refuges", "Parolec", "Asylee’, or "Notice of Action” OTHER INCOME OR BENEFITS TO FAMILY UNIT: Documentation must show the rate and frequency of the income received from the sources below: [_] Unemployment documentation {[] Pension documentation [E] Worker's Compensation [1 Social Security award letter [1 RetirementiPension [1 spousal SupportAlimony (] Veterans/Miltary Benefits [Disability Benefits [A child Suppor - minimum of 6 months of PaymentiDisursement History {Wolf ile suppor alimony i not court ordered, wie tho ‘aout you cave monthly in Secon C ofthe application) Lo Any other income required for federalistate tax reporting purposes DFO 10-17© Bets 3/1/21 - All Other 2021-2022 INCOME ELIGIBILITY SCHEDULES FOR PUBLICLY SUBSIDIZED CHULD CARE ASSISTANCE or SERVICES Tacome Hligibiity for the Child Care Assistance Program “Ste Funded and Otter Selected Child Care Programs Including Preschool ‘Kiashlp ‘Wrap Around Child Care Administered throtgh the Child Core ‘New Jersey Departinent of Human Services ‘Services — ate atthe 21 Fenty eter Federal ‘Sa Poverty nde. Bevery sex sete Mein 1 $22,540 $32,200 360,404 $45,080 $64,400 2 817,420 $30,485 $43,550 $74,317 $60,970 $87,100 3 $21,960 338/430 $54,900 594,389 $76,860 109,800 4 $26,500 $46,375 $66,250 112,802 $92,750 $132,500 3 $31,040 $54,320 $77,600 $120,452 $108,640, $155,200 6 35,580 | 53,370 | 62265 $88,950 $128,102, $124,530 $177,900 7 $40,120 S700 100,300 $135,752 $140,420 $200,600 8 $44,660 $78,155 111,650 $143,402 31563310 $223,300 9 $49,200 $86,100 123,000 $151,052 $17.20 $246,000 10 $53,740 $94,045, 81343350 $138,702 $188,090 $268,700 "1 $58,280 101,990 | $116,560 $145,700 $166,352 $203,980 $291,400 62,820 $109,935 | $125,640 $157,050 $174,002 8219870 $314,100 : $15,890 $22,700 ier Bprses ha ea tine Gate Sout Csesr Brae Moda Fel osns by Fal Site, Deputman of ean, Caes Pl as of Novas 1200, puesto ge!Service Eligil Child Care and Early Education ity Application ‘STATE OF NEW JERSEY # DEPARTMENT OF HUMAN SERVICES Applicant instructions for Completing the Child Care Eligibility Form “The following instructions are keyed to the various sections of this form, Please read carefully. > INSTRUCTIONS FOR COMPLETING SECTION A 1. Enter your ful name (last, fist, middle inital), social securty rhumber and dato of birth (month/datotyear). Check one oF more of the appropriate boxes provided to indlcate your race. Check the appropriate box to incicate your ethnicity and sex. Check the appropriate box to Indicate tha relationship of the parent! applicant to the child(ren) for which you are making an application for assistance. If you are not an immediate relative (motherifather), please indicate whether you are anather legally responsible person, a foster parent or other. If other, please specity, 2. Ifapplicable (resides In household), enter the full name of your spouse or eo-applicant, soctel security number and date of bith (monthidate/year}. Check the appropriate boxes provided to Indicate the race, ethnicity and sex of the co-applicant/spouse. 3 Enter your home address and county in wihich you reside. Enter the school dstiet which the chila(ren) attends. 4, Enter your home telephone number, 5. Enlor the “amily size" meaning the number of adults (persons 418 years of older who are legally responsible forthe children) and dependent adits (persons 18 years or older) who ar in your immediate family unit, and the number of dependent children (persons under age 18) Examples: In a single paront familly with two children state “Hof Adults: 4, #of Children: 2° Ina two parent family with a dependent adult (grandparent) and {wo chilron state: "¥# of Adults: 3, # of Childran: 2." Note: If'as.asingle parent, you an your child(ren} tive with your mother and father, you would NOT include the grandparents in the family size. > INSTRUCTIONS FOR COMPLETING SECTIONB. Provide Income Information Based on tho Curront Yo Fill In All Blanks. List Gross Figures Unless Otherwise Indicated. If You Receive None in a Certain Category, Write “0." Fr each alt (applicant co-applcant or otter depondont alt) residing in the household uni ist all current income information. CCaluras are provided to antorincoms information either by week, covery two weoks, month or year. Far separated or divorced spouses, Inaluda only that income (Le, eilé support or alimony) whic avalable othe custodial amily 4, List all grass income du to wages and eatery. 2, Llst all beneft Income recelvad from pensions and retirement. 8. List all benefit income received from Supplemental Soourty Income (SSI) : 4, List all benefit income received from unemployment and workmen's compensation. 5. List all benefit income recolved from pubic assistance (TANF), 6, List income recsived from an absent parent for child support or alimony. 7. Include any other income recelved which is requited to be listed {or faderal and state tax reporting purposes, 8, Indicate the annual total of all sources of income, > INSTRUCTIONS FOR COMPLETING SECTION Provide Information of Curront Work, Schoo! andior Training Activity for Applicant and Co-Applicant ( applicable. 4. Enter the name, compote address and telephone number of Primary Work/School/Training Sit. 2, Chack tho appropriate box to indicate If activity is work, schoo! or training. 3, Enter your stating date (month/datelyear), ‘4, Check the appropriate box to indicate if Work/School/Training activity is fll ime, part time or seasonal, Enter the number of hours por weak and months per year spent at site, 6. Include the information for your Secondary Work/SchoolTralning activity (if applicable). > INSTRUCTIONS FOR COMPLETING SECTIOND Questions 1-9. Check the appropriate box (either “Yes” or “No*) for each question. If you answer "Yes" to any of questions 2-5, provide the requested information. Questions 10. Check the appropriate box to indicate if you are applying for assistance because you are ineigibe for the TANF or TCC programs, ‘Quastions 41. Check whethor you understand you are applying {or voucher oF contracted child care services, ‘Questions 12, Cheok whether all ofthe children in your family have hestth insurance and if you wish to receive an application for NJ Family Care. > INSTRUCTIONS FOR COMPLETING SECTIONE. 41-2. Enter full nama (last, st, mile initia!) soctal security number and date of birth (monthfdate/year) for each child for whom assistance is requested. Check the appropriate boxes provided to indicate race, ethnicity and sex of chien). indicate the hours, days and duration for which child care is needed. Check the appropriate box to indicate Ifthe child(ren) has a special need, if ys, stata the need. Check the appropiate box to Indicate if the chidd isa US clizen Iryes, attach a copy of the child's bh certificate and soclel security card. Proof of the child's cltizenship is not required for Abboll, Child Protective Services, Kinship or Post- Adoption sibsidies. > INSTRUCTIONS FOR COMPLETING SECTIONF After reading the certification, applicant and co-applicant (if applicable) sign on the appropriate line and Include the date. Rov 12108ny 4CS of Passaic Count = 2 Market Street Suite 300 Child Care and Early Education Paterson NJ 07501 Service Eligibility Application Ss STATE OF NEW JERSEY « DEPARTHENT OF HUMAN SERVICES Applicant/Co-Applicant Information aoa P P er All Q ty “TPARENTIAPPLICANT NAME SOCIALSECURTY NO. DATEGFBIRTH pate gy —— es The fouing nomad an sea pposox. Gree ane or mont he ppopat bowers sete pant response, ace: Amorican idan or loan Cl Asin Bleck or Aeon drorcen Native Hawotan/Peei andor Who Enact Hapanicliatne: “OYes No sex OMe Female Rolaonship of APPLICANT o chien: Father Mother CTLagely Response Adu Foster Parent Other: 7, PARENTICO-APPLIGANT HAE (TF AppTeabIo) ‘OGTAL SECURITY NO. DATE GF BIRTA gg ag a i uma) ‘Th folowing orate 8 now frst urposos. Goes om or mar the appropri oxen nae appcnt ospnse. RACE: cl American Indian or Alaskan Cl Asian C1 Black ar Afcan American i Nelle Hawalan/Pacifi Itander C1White eric: Hieponicfatne: OYes CNo sex [Male Female [5 Home ADDRESS (Number and Stet) (oD eF ory Sine, 2p Gods: Couniy: ‘Schoo! Distict _ 4, HOME TELEPHONE: 5. KUMBER OF ADULTS IN FAMILY: [NUMBER OF CHILDREN I FAMILY: ‘ToraL Faamy size: Family ze ncades parent, spouse, chia fr wham subely i requosted, afer dependent han, or adults claimed on appHe@at Sor. applicant's IRS 1040. near of ina, family sie ncides the Id fr whom subsky is requested and all dependants claimed onthe grandparent, aunts or ‘plate’ IRS 1040. Por DYPS casos, a hl and any ofhlsher slg fing ne sams harmo and who aro In DYFS-paid ou of home placement shall be counted to determing tho sze of te family. Family Income Information : Foreach source, anor Income Information| CO-APPLICANT mr Shor by wook, blaraokly, month or yoar Lust gross Income far curant: Lstgross income for current: Include els support andlor aimony. Week weeks mowTH ver | weex 2 wWeeKs EAR 4. Wages ane San ors 2.Penslons, Retiement 2, Suppanantasocal Scunty Rane 4. Unamployment, ches Compensation: 45. TANF Cash Aslstance 6-chta Supporvation othe 8. TOTAL GROSS INCOME: ‘WorkiSchoolMraining Information akekouaiheaian 5 7 EIN Nae of PREARY Woah St Compl Ades (Beet Cy Sa, 8 (rasp eat empty} Se (a cece ECE Cee eeeeeee hook One ctr Stngoate flay] Woe Sed Tig came CSmos Tang be . Stenbabe fp Stat Onto ff Chuck One sud Ener Nunowct tous] CrutTine Gating ————— tie | crultine CiPatTine Hat Weekend Mentear ir Woidealtaning| (}SateonaEnolymen! ——_——#Meatr | CSeseot enpymert eave Tene a SECONDARY WsSantanng Campi eos (rec Cy, S220 ee fees cece income Siaea ba aioyrs] WAR Std aka Sink eae tenn iO pL ow Check nw and Ener Nunbarttinn| CRATING Ceentne ————— stan | CofutTme Cpa tm ——— stat eskarsuionisoartrWentcmaalrg] ClSennetEmpeynent Aart Cseounalempomert en * Incomplete Applications Will Not Be Accepted * are (9272000)ns Will Not Be eigenen {All Questions Must Be Answered. Incomplete Appl err Bria eeetaen ied eer 1. Are you cuenly partesratng Inthe Food Stamp Progam? 2. ve you cuenty rooekinghave you received assistance for child eare wih a Tamporey Assistance for Needy Famnios (TANF) or Transtional Ch Core (TCC) grant trough the Work Fest New Jersay (WEN) Program win tho last two years? If yes, ndleats when benefits doldid empire by entering Month, Day and Year___/ _/_and TANF case number; ————________ 1 C1 2. Je your fay an active eae wth the Division of Youth and Family Sensos (DYES) nd aro tho cilion for whom you are roquestng “subsidy residing with you? yes, pease give te name ofthe foe: 11 01 4, Axe you cent receiving a TANF grant? if yes, please indicate the TANF case camber: C1 5. bo you ora member of yur fay have a conic mada problem for which cid cares recommended as pat of a reatmentrebitaon lan? If yes, nate the nara of ho Indhldualagency authoring the treatment plan and telephone number: Agency Name: Telephons#( [1 6, Are you the head of the household in which you rosie? C7. Ae you curently homeless or at risk of becoming homeless? [11 @. Arethe chide for wham you av requesting hl ear assstanco ina DYFS foster home, DYFS para-oster hom, or DYFS pre-adopive og oo home, If you are employed or participating in a schoo! or telning program, proof must be attached for DYFS purposes. ‘Do you reeaWve any cash oF voucher assistance to speciicaly pay for housing? ‘Aro you requesting aesitance because the County Welfare Agencycard of Social Services (CWAIBSS) informed you that you are ‘nakgiblofor the Ternperary Assistance for Needy Farias (TANF) ar Tansitonal Child Car (ICC) Program? “TL. understand het em applying othe agency er: C] VOUCHER payment asssisnco CL] CONTRACTED services ina comunity basedoantor 412, Doallof the children inthis family have health insurance benefits? Yes 1 No ITN, do you wish to receive an application for Nu Family Care? C1 Yes] No IIs eran user) Use Addendum Form to Provide Information for Addiitonal Children. FULL WANE OF CHILD NO. + ‘SOCIAL SECURITY NO. DATEOFSIRTH aay —— Fy bit at (MorBy¥e) ‘Te folowing Information fs noeded ‘or sttstsa! purposes. Check ono ar more ofthe appropriate boxes fo ideale apploant response. face: C]AmerleanindanorAesken LC} Asian BlackorAficanAmerican (Nave Hawatan/Pactic lander CL] White eTawrry: Hispanicd.atno: (ves [INO sex: (Male () Female Indicate the houridays/duration for which chid car is needed: Childhass specialnocd: No C1Yos_Ifyes, state epocial need and attach verification: Chidisa USettzencraquatfedaten? CINe Yes. Ityes, attach verification (copy of Social Security Card and Birth it applicable, Resident Allen Card) ‘AGENCY USE Salus (CHEK One TTaried—TTAnproved—(]Waling ist [Tending DYFS USE; (Eniorho NJ SpittCase No) Progra Code:___ Component: Assozsed Co Payment (Erle and Cee Ona 8 We Mo, Ewaimetoae —// FULL MAME OF CHILD NO. 2 ‘SOCIALSECURTY NO. DATEOFBIRTH (ast ii) My eigtNumte) (Mo Bye) ‘The folowing infarmation fe nooded for slasoat purposes. Check one or mare af the appropriate boxos fo Iccato applcant response. RACE: CJAmericanindianorNaskan ChAsian —[] BlackorAficenAmercan LJNaveHeweian/Pacte lander C1 Who eminem: HispanietLaina: Cl¥es CINo sex: CMale (Female Inleato the hourtaystduratian for which chld care is neaded: Chiidhasa specialneed: CINo Clea. Ifyes, state special need and attach veriicatlon: aisoneeeeeeet Chidisa UScltzenoraqualiedalien? CINo CI¥e8 ifyes, attach verification (copy of Social Security Card and Birth Certificate or, If epplicable, Resident Alien Card) "ROENGYUSE: Salve (Check One): CIOenied C)Approved [Walling List] Pending DY Se Erte pit ato No) —___-_ Pro component: Assessed Co-Payment (tar and Cicl Ona): §_ we speci FULL NAME OF CHILD NO, 9 ‘SOCIAL SECURITY NO. DATEOF BIRTH (Lasty Fe) @oigitimee) Wey a ont oman aed fy ate papas. Chek ooo woe th apvopine bot net apa mapa, CiamaricanindaneralaskanCJAsan[}SlackorAficanAmercan CINativeHawaiaPactclslander C1Whte “romeire Hepenchalna: tives CIN sex: CiMale Cl Female Indcate the houréaystduration for which childcare is neaded: Chiighasaspeclalneed: —CINo C1] Yes ifyes, state special nead and attach verification: ChidisaUSciizen ora qualitedalion? [No [Yes ifyes, atlach verification (copy of Social Security Card and Birth Certificate or, i applicable, Resident Alien Card) ‘AGENGY USE: Situs (Check One) CIDowied Cl Approved CiWatingust Pending DDYFS USE: (Enero NJ Spt Case No) DHBreCre (108)"ADDRESS REPLY TO! PavoralappicantName _ Socal Security Number: a pagotbin: 7 Al OF u DATEOF Bi ee ee Z Taal Fed way ‘Git Numb} (oDyNr) ‘The fofowing infomation fe nosded for selislical purposes: Check ane or mara of the appropriate boxes (0 indete apeicant response, race: Cl AmoricanindianorAlsean CJAglan () SiackorAffean Amarican L Naive HawatanyPacticlsiandar C1) While eTHWi: Hiepanie/.atine: C)Yes CNo sex. OMale Ol Female Indicate the hourldayséduration for which child caro fs needed: Childheeaspedalnoad: CINo ClYes _ityes, state speclalnood and attach verification: Chidis US ciizen ora qualied allan? [INp Cl¥es.IFyes, attach verification (copy of Soclal Security Card and Birth Cerificate on, if applicable, Resident Allan Card) TAGENOVUSE: Salis (Check Ono} LDenied Cl Approved C]Walinglist — C)Pendna DVESUSE Ertw NI SpHRCasOND)_—__—— Pra: Code: Component ‘Assessed CoPayment (Ener and Cire One) $. Wk. Mo, Entiment Date: _f __/ __ 5) Fut wane oF on9 no. 6 SOCAL RCURITYNO,—__DRTEOF BRT —— 3 a Rigid The flowing formation x noeded for las puposes. Check ne oc more ef th oppose bows oindeteaopleart response RACE CT American indian oralaskan C1 Asian [) ladkorAfican American L) Native HawalinPaci lander LI Wile EvHMc: Hlspanlel.stine: ClY¥es CNo sex OMale Ol Female Indicate the houréays(duration for which childcare ksneedad: Childnasaspeciaineed: CINo C] Yes _Mfyes, stato spoclalneodand attach verifications Chidisa US aitzenora quatfed len? CINb Elves. IFyes, atlach verification (copy of Social Security Gard and Birth Cerificate or, it applicablo, Resident Allen Card) "AGENCY USE Sat (Chesk Ono _CiDened U Apres ClWangtist ClPendng DYFSUSE: ert NISpHCaseN)———————_ Prgrans_____ Code; ______ Component assed CoPaen (Ener and Cra Oy $= Wk Mo. nora Dt: G] Fon wane OF HD NO« SoG SECURIT NO, DATFOFATH Tasty (First AT) —“evigtivumbor) (May Ar} The flowing fama nosed fo lasticalpuposes. Check no or moro th oppopiote boxe to indeatoarpleantragens> face. “armateanndanerAgsian C’Atan”c] BackerAticanamorcan {I NaiveHavetanPechstiendar” (3 While TANI: Hispanlo/atine: ClYes ONo sex. Male Ol Female Indicate the houréayelduration for whlch childcare is needed: Childnasaspecalnoed: CINo [Yes tyes, stato special nodand attach verification: ChidigaUS iizen ora qualfed len? [INb Clves ifyes, attach verification (copy of Social Security Gard and Birth Cerificate or, if applicablo, Resident Allon Card) Toenied approves Clwatng list — DPending| [AGENCY USE: Salus (Check Oro) SYESUSE:(Enerto NJ Spek Case Na) Prams te: _ component ‘essed CoPaymen (Ene and Ceo Ore} §____Wk__ No. — emer Baer 72 "7 | FaLL wane oF CAD NOT SOCAL SEGURITYNO, _DATEOF BRT. oe I ray ray aT ‘Gola ania (uae) Tho fooing infomation food fe teal purposes. Check ono or mare ofthe Tees fo eateapptcant reponse. ‘AmercantndancrAsckan LI AslanLIBiackorAticanAmarcan CINalveHawaiarPachotonder C1 Whto etHwiciry: Hispeniciatne: CI¥es (INO sex. OMale (Female Indicate the hourfdaystdurallon for which child cares naeded! Chitdhasaspeciaineed: CINo 01 Yes Ifyes, state special needand attach verification Chiidis a US citzen ora quatfed alien? CINb Ll¥es. iFy0s, attach verification (copy of Social Securlly Card and Birth Cerificate or, It applicable, Resident Allen Card) ‘AGENCY USE: Stlue (Chock One} [Denied []Approved —]Wallng st [)Pendhg| DDYFSUSE Enfar tho NJ Split Case No) Program: ode: ‘Component ‘Assossod CoPyent (Ere ard Cle One) § Wi. Mo. Exot Date. ‘ASICS ZA THChild Care and Early Education Service Eligiblity Application Certification READ CAREFULLY BEFORE SIGNING | (we) hereby certly that al ofthe information provided is true and correct tothe best of my (our) knowledge. 1 (we) know thet submiting false Information about my (our) situation, falling to give the necassary information or causing others to hold back information Is against the law and may subject me (us) to prosecution. | (we) also understand thal: 41, Acceptance of child care financial assistance is not for my (our) personal use or expenses and that federal, state and local public, funds are and wil be used as payment for costs that are directly associated with services rendored by a child care provider. 2, iis Unlawful to obtain fnanclal assistance for child care corvices by providing any false or misleading information, including but not limited to lformation about my elighlity and/or information that relates to child attendance for provider records, sign-in sheats or ‘voucher payment fons. Examples of unlawful behavior include, but are not limited + Faliing to accurately raport all sources of my (cur) Income, Examples include, but are not limited to not reporting multiple sources of income, or an increase or decrease in wagelsalary, child support payments, or alimony, or any other Income. Failing to accurately ropor the amount of my income. Examples include, but are not imited to reporting the accurate amount(s) ‘of Income fram self-employment; rent from property ownership or changing or altering pay stub information. Falling to accurately repor the number of housahold members. Examples Include, but are not limited to falling to report that ‘my spouse or another parentiguardian is living in the household, Pro-signing and dating voucher cerifcation forms, sigh-n sheets or other provider records used to track and verify child attendance. Falling t0 accurately varity child attendance on voucher payment records/forms whhin the reporting timeframes. ‘This information is being given in connection with federal, state and local public funds and will be used through computor matching programs to confinm the accuracy of my (our) statements and verity my (our) Income, resources and neod for child care assistance, 138 Warranted. Providing the requested information, includiag the Social Security Numbers of Perent(sWApplicant(s), is voluntary. Agenoy staff may ‘use my (our) names and Social Seouriy information with fedaral and stato agencies end other sources deomed necossary for offal examination, Howaver, copies of birth certicates, sacial security and qualified alien resident cards, if applicable, are required for all children for whom subsiday services are boing requested, Failure to provide or delibarate misrepresentation of requlred information will result in the denial of my (our) application, termination of child care benefis tothe family and referral to fedoral, state or local agencies for criminal or civil court action, garnishment of wages or tax interoept, as well as private claims collection agencies for claims action involving repayment and recovery of funds, Providing false or misleading Information in connection with my (cur) applicallon for child care financial assistance, andlor failing to report within ten days any change in my (our) family size or family income or any other circumstances that might change my (our) cligibllty, euch as work/scheotizalning status, may rosuk In the termination of my (our) child care subsidy and make me (us) Ineligible to apply for andior receive subsidized child care for a period of six months forthe first violation; for a period of 12 months for a second Violation; and permanent disqualification for the third violation. 7. If reealve financial assletance as a result of falze or misleading information, | (we) may be responsible to repay the costs of child care and may be subject fo a civi fine and possible criminal prosecution. 8, Ie) understand that in order to verify my (Our) income and service need, an agonoy representative may nood to contact my (our) ‘employer(s). | (we) horaby authorize my (our) employer(s) to release information regarding my (our) Income, pay scale, hours and schedule of work tothe agency to which I am applying PorortiGuardian Signature: Parantuardian Signature: ‘Unsigned applications canmot be processed, A copy of thls document wil bo provided fo you for your records. DYFS USE ONLY DYFS Case Manager Namo and Number: Date No SAR hae boon completed; voucher paymants for DYFSICPS child care services are approved forthe period ftw DYES Vouetr Payment Authorzation Signature: Date ‘CCR&R of CENTER BASED CONTRACTED (CBC) PROVIDER USE ONL) Check One: CI tial Appicaton C1 Re-detennination Geatiicaton Date: Family Size. Anal Far incom: §. Family Tolal Assessed Co-Paymant, if applicablo (Entor Amt and Chock Ona): § owe Dorm ‘Ghock One: CIDENIED [| APPROVED C1PENDING ‘Sta Mambar Certiestion: Date: Not: ‘Nome of CCRER or CBC Provide: ‘DBI: (205cc-t62 (Rev 4287) N\ srare or new sense RY) bepaamven oF Hau services J) ise oF FaMLYDENELOPMENT NJ CHILD CARE SUBSIDY PROGRAM Application Addendum Al families receiving a subsidy through the NJ Child Care Subsidy Program must provide the following information: ‘Are your farnily assets worth moro than $1,000,000? []No [_]Yes Node: Asels may include but are not inited to, porsonalbenk accounls, business aecounts, realestate, ae porsonal preperty. Ifthe primary language spoken in your home Is not English, please speolfy that language: Js the Applicant: On Full-Time Active Miltary Duly [JNo [Yes {nthe National GuardiMiltery Reserve [JNo [7] Yes Self-Employed No Les Is thera a Co-Applicant? Cine Eves Hfyos, aro they: ‘On Full-Time Active Military Duty (No (Yes In the National Guard/Military Reserve [No [Yes Self-Employed (No []Yes ‘re you homeless based on one or mare ofthe following? No C] Yes « Living in an emergency of transitional shelter, « Staying in a motal, hot, ale park, or campground or sharing housing with other persons du to loss of housing, ‘econcmit: hardship, or sila reason. + Living na car, busfan station, park, abandoned buiding, « Living or sleeping in any public or private placa tha s not normally used as a residence or as a regular sleeping accommodation. + Lvingin substandard housing (6. no elect, running watar, et) al Urey crtty that a of the information provided is tue and correct to the best of my knowledge. | also acknowledge that -submiiting false or misleading Information, intentionally omitting information or intentionally causing others to omit ar fail to report information is cause for denial or trmination from the child care program and | may be subject to al logal and equitable remedies. ‘Rppicant Namo ‘Applicant Signalre Dale Co-Applicant Name ‘Co-Appicant Signaiire Date DISORIMINATION ‘i asamp cen dia iy ie ol yoann da ast aay aca Say Pega ee ain her ahernn oncc ‘orf Fre amon ep Sede Fo ae, ea OS41Cs OF PASSAIC COUNTY, INC. Applicant Co-Applicant Race {check all that apply) ____ American indian or Alaska Native: A person having origins in any of the original people of North and South American (including Central America), and who maintains tribal affiliation or community attachment. Asian: A person having origins in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, india, Japan, Korea, Malaysia, Pakistan, the Philippine islands, Thailand, ond Vietnam, Black or African American: A person having origins in any of the black racial groups of Africa. Terms such as Haltian, Jamaican, Migertan, Senegalese can be used in addition to Black or African American, Multiracial: People of more than one race or ethnicity. Native Hawallan/ Pacific Islander: A person having origins in any of the original peoples ‘of Hawail, Guam, Samog, or other Pacific Islands. ‘White or Cuacasian: A person having origins in any of the original peoples of Europe, the ‘Middle East, or North Africa or any of the white racial groups of those regions. Ethnicity {check one) Hispanic/ Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, cor other Spanish culture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic or Latino.” et Not Hispanic/ Latino ‘Towhich gender identity do you most identify? —— Female Male Transgender {female/male) —Non-binary/non-conforrming —_Agender- don't identify with any gender “Gender not listed: My gender is Prefer not to respond This information is for statistical purposes only 2 Market St (Paterson Museum Building) Suite 300, Paterson NJ, 07501 » Acspassaic.org * Info@ Acspassaic.org + Phone (973) 684-1904 « Fax (973) 684- 0468.ACS OF PASSAIC COUNTY, INC. AUTHORIZATION TO COMMUNICATE VIA INTERNET By entering your email address below and then a second time to verify its accuracy, you are granting permission to 4CS of Passaic County, Inc. (4CS) and confirming that you are aware that you will be receiving confidential, time sensitive information and other program and agency information from 4CS regarding your child care subsidy and general correspondence. Make sure that you check your email regularly to ensure that you are receiving all the documents issued to you from 4CS, Please take note that if you do not respond in a timely manner, there may be a disruption in your child care subsidy. So, please be consistent in checking your email. Critical times to look for emails from 4CS are but not limited to the following: ¢ Change in Child Care Provider * Change in Employment * 465 days prior to your Annual Redetermination (every 12 months) Email address Email address verification Please print and sign your name below confirming your permission and authorization. Client Print Name Date x (Client Signature) ‘Wo Matt Set Pierson Maas Bing) Pan, NI, O7501 «doaieasé. og hfocMespasssecra Pon (73) 694-1004 «Fax 079) 694.0468,240-2 ICS 4CS OF PASSAIC COUNTY, IN ‘Two Market Street, Paterson, NJ 07501 « Phone (973) 684-1904 + Fax (973) 684-0468, Child Care and Early Education Service Eligibility Parent Documentation and Verification Certification Employer's Letter Employer's letter was provided by employer Family Income Information ____ reported and submitted all the income information that I receive, This includes SSI, Supplemental, | Child Support, or any unearned income Family Household Size My family size unit only Includes the number of adults and children as stated on my application Ttis unlawful to obtain financial assistance for child care services by providing any false or misleading information, including but not limited to information about my eligibility anc/or information that relates to: — Falling to accurately report all sources of my (our) income. Examples include, but are not limited to 10 reporting multiple sources of income, or an increase or decrease in wage/salary, child support payments, or alimony, or any other income. = Failing to accurately report the amount of my income, Examples include, but are not limited to reporting the accurate amount(s) of income from self-employment, rent from property ownership or changing or altering pay stub information, — Falling to accurately report the number of household members. Examples include, but are not limited to falling to report that my spouse of another parent/guardian is living in the household. This information is being given in connection with federal, state, and local public funds and will be used through computer matching programs to confirm the accuracy of my (our) statements and verify my (our) income, resources and need for child care assistance, as warranted, Tcertfy that the foregoing statements made by me are true. Tam aware that if any of the foregoing statements made by me are willfully false, T am subject to punishment and may be terminated by the child care subsidy program, Print Applicant's Name Print Co-applicant’s Name Signature Signature ‘Website: htto://www,4espassaic.orgZN ICS 4CS OF PASSAIC COUNTY, INC. Two Market Street, Paterson, NJ 07501 « Phone (973) 684-1904 « Fax (973) 684-0468 ACKNOWLEDGEMENT OF CHILD CARE POLICY REGARDING DISQUALIFICATION OF SERVICES FOR PARENTS T acknowledge receipt of the State of New Jersey Child Care Policy for Disqualification of Services for Parents dated 7/7/14 DFDI 14/07/01 from 4CS of Passaic County Inc. I have read the Disqualification Policy and understand my rights and responsibilities for the subsidy programs I am participating in, Parent Signature Date Parent Signature Date Print Name | Print Name Return sic wledgement to 4CS i Website: http://www. Acspassaic.org4CS OF PASSAIC COUNTY, INC. CHILD CARE POLICY REGARDING DISQUALIFICATION OF SERVICE - STATE OF NU INSTRUC DATED o7o7t4 rente/applisante. ara all imes, fo comply with Now Jersov'e subsidized child care program reaulatione ‘and police, ‘Ary ype of program violation wil subject a parenY/applcant to penalties that may Include dsquaiicaion, termination, denial at time of application or reapplcalion, cifminat Investigation andlor recoupment of peyient, if the parenfapplcant le found by the (COR&R or DHSIDFD to be in violation of New Jetsay subsidized chi care program regulations and polices, DISQUALIFICATION PROCESS ‘A case of program violation can be brought lo the Department of Human Services, Division of Family Development's (OFD) ‘andlor CCRAR’s attention through « varity of means, such ae & phone call, Iter, -mnal, newspaper artic, telavslon news roadcxsl, persona Knowledge, or stala databases used duting the noimal applicant lily dotemmination and redetermination process. Tho CGRAR wil then conduct an investigation to determine whether or not the program Violation fs substantiated, The CCRBR shall seek DED guidance on casas In which calfealon is requir, A substantiated case of program violation will reut in the suepension or aiaqualfication of chiki care subeldy end make tho paront/epplcantinaligiblo fo applyraepply for andlor recaive subsidized child care for @ specified period of ime depending upon the ruriber and lype of vilaions, A paren or applicant may appeal the decision fo suspend or terminate the child care subsidy. “The stops to take lo suspend or disqually a parenfappticant child care subsidy for various vilatfons are outined below, ‘Generel program violations that may resuitn suspension o dsquaiicationinchude ut are riot tinted to the following (1) Failure to roport within ton (10) calendar days any change in family sizefcomposiion, famiy ineome or any other lrcunslances that change ellgbily, such as woiklechooltaining stsus of incane thal exceeds program specie Federal ovary Lovel (FPL) requiroments, etc. @)_ Fallure to accuraloly roport ell cources of income. Example include, but are not fnited to, not reporting multiple Sources of inesme (multiple employers), or an increase or decrease in wagelsalary, child support payments, oF alimony, tinemployment, workman's compensation, pansion, cupplomenta| security Income (SSN, socal security csably Income (SSD), sunvor banofis or any other income, (3) Fellur to accurately report the amount of income. Examples include, but are not imted to, not reporting the accurate ‘moun(e) of income from set employment, rent from propety ownership, of changing oF tring pay stu information, (Failure to accuralely report the number of housshcld members wo are racuires to ba counted to determine family or Household composition. Examples Include, but are not ined fo, fang to repod thal 2 epouse or another perenguardian fs livngin the household. ECC~ Progeatn Violation Felure to comply with the E-Child Care ParenProvder Responsibilties and Agreement may result in ® warning notice, suspension or disqualification. PENALTIES/PROCEDURES Warning Notlee Upon evidence of an E-Child Caro program viotaon, tho COR&R has seven (7) calendar days to send a warning letter (see aliached) tothe parenls are offer training. CCRARS are requed fo provide wien notification of parental warning to providers. For WENJ cases, copies of sl notices must also be sent to the County Welfare Agenoy (CWA). The patentispplicant wal have Up to two weoks (14 days) fiom the dale of the waming latter to alten tang and remedy the action by demonstrating ‘onsisfent use of ECG. To document compliance or noncompliance, the CCRBRs must print out the transaction repot for that ‘wo-weak pari once tho 14-day back svipo poriod has losod, Gonoral Program and ECC Violations Penaltios ‘Waring Notice Upon evkionce andlor ntieation of a program volatin, tho CCR&R has seven (7) calandar days fo send a warning latter (gee attached) (0 tha parenfguardians. CCRARs are raspensiie for taking the necessary acon to determine if the parenifguarden remains elif and if repayment of funds is required,First Violation (oxcept fraud) = Ono (1) month disqualification Upon completion of he cna month disquacaion, if the case s eligi, redetermination rules will apply. The ellgbltythrashold {260% of he Fedora Poverty level (FPL) or below (360%-500% FPL for Kinship). WFNG eases wil require writen nalice ta the CWA and vorietion that the CWA was informed of tha dlequalifcain, Second Violation (excopt feaud) ~Threo (3) months dlsqualitfeation Upon completion ofthe three month disqualifcatcn, ifthe case fs ego, redetermination rules will apply, ‘The rodaterrinaion cligiity threshold is 250% FPL or below (950%-600% FPL. for Kinship), WEN cases wid require willen noice fo fhe CWA and vercation that the CWA wes informed ofthe dlequalicaton, ‘Third Vioiatton anor Fraud — Termination for up to twelve (12) months andlor permanent disqualification ifthe violation has not resulted in permanent dlsqualfcation,pasent cau be eubjact to up to a twelva (12) month termination, Ser which the parentieppicant must reapply wih the algly threshcld bengal 200% FPL or below Fraud or} ok ubject to up to a twelve (12) month torminatfon Inelude tho following, (G1) Fellare to provide, or provislon of, false or misleading or deaberale misiepresentation of, required information in connection with a nev application cr current child care eubely case. (This may also result in the dene of any eu, and referral fo federal, tale orlocal agencies for criminal or vl court acbon, gamlshment of wages or lax Itercept, 25 \Wol as pivete aims colocton agencias for cana action Invcving repayment and recovery of fds) (2) Reporting chéden) present in altendance whon child(ren) were notin altendance, {@) Repeated misuse ofthe ECC card rosulting in multiple volaions, (2) Reposted genora! program violation resulting In multiple olalions WENJ cases will requre writen noon to the CWA and verification thatthe CWA was informed of the termination for up to (weve (12) months, Appeal Procedures: Its the right of every parent who receives a disqualicalion notice from the CCR&R to request a raview of hiaher case by the CCRAR andior DED, The COR&R must inform the parent of hlefhor right to request a reviow. A timely requast must be made ‘within tn (10) days ofthe date ofthe dlequaification note, See information on appeal rights below: CHILD CARE PROGRAM APPEAL RIGHTS 1 Case review conducted by the county CCRER Agoney In the ovant you wieh to have the ection or amount in quastion reviewed by the counly CCRER responsibe for the dectsion, your ‘must make this request n writing wihin ten (10) days of the otfecive dete of the adverse decision, Requasts should be addressed to the agancy on the front ide ofthis natoe You will be nolfed of the date and time of the review and you may appear with or without lagal reprasontaton or may be represented by a filend or otter spokesperson. Only those parsons dieclyinvalved wit the Issue wit bo peri to attend _ay review proceadings, You wil also_be given an opportunity to view al portent dacumanta prior to the review data, 2, Administrative reviow conductod by the Division of Family Dovol ‘You may also havo an adverse decision reviewed by the Dison of Family Development (DFO) in place of, rin adaton to, the: ‘caso reviaw conducted by the couny CCR&R, A roquoct for an adminisvatve review from DFD may be made by calling the Bureeu of Administrative Reviow and Appeals (BARA) al 1-800-792-07, ‘You wil be coqured to submit the following fo BARA ‘Arion statement indeating the request fora review and tho raason for your dsagrooment, ‘*Alldocumenis verifying etgbilty and justifying your case; ‘© Aay other relevant documents which you befieve the county GORSR or ‘il caro provider may not have considered. This DFD review must be requested witin 90 days of the dale ofthe original notice of adverse action, All materials should be mall to BARA at Burwat of Adminstave Reviow and Appesls Division of Family Dovelopment P.0. Box 748 “Trenton, NJ 08628-0718,Finding Quality Child Care ae Finding a Quality Child Care or Early Learning Program Research shows that children who are in quality child cate and early learning programs when they are young are beter prepared for kindergarten with better reading skills, more math skills and larger vocabularies. Grow NJ Kids, New Jersey's Quality Rating Improvernent System, is working to raise the quality of child care and arly learning across the state of New Jersey. For parents, it provides information on selecting a quality provider to help them make the most of their kids’ early learning opportunities. Home-Based Setting: Family Child Care This type of care is provided in sameone’s hame. In New Jersey, a provider can care for na more than five children, plus a maximum of three of their own children. Home providers can choose to be registered, which means, they meet the basic safety and programs requirements established by state law, This registration also allows these in-home providers to accept payments from families participating in government-subsidized chilé care assistance programs. Center- and School-Based Settings: Child Gare Centers Licensod by the state of New Jersey, these facilities are ingpected every two years and must meet basic heolth, safely, program and staffing requirements. They can care for six or mare children from the age of 6weeks to 13 years. There are many types of licensed child care centers, including but not timited to infant/teddler programs, early care and education programs and school-age programs. Licensed centers also may choose to meet more rigorous, research-based or accreditation standards. (There also are license-exempt centers, such as programs that are part of 1 public school district or private schoal.} Head Start and Early Head Start programs support the ‘mental, social and emotional development of children from birth to-age 5. in addition to education services, programs provide children and their families with health, nutrition, social and other services. For childcare and eary learning programs, it provides resources that help them raise ther quality and continuously improve their program. ‘There are many types of child care or early teerning programs to choose from. Some are ina school others ina child care center or in someone's hore. In-Home Care In this type of cre, a person ‘comes to your home to care for your child, This provider might offer other services such as light housekeeping, starting ‘or making dinner or driving your child to agency to find such a provider, they are neither regulated nor licensed by the state and cannot participate in Grow NJ Kids. School District Preschool Programs School districts provide research-based preschool Programs for’ and 4-year-olds, that may be located \within a school district site, a private provider ar a local Head Start agency, Special Services School Districts ‘These districts provide options for preschool students with special needs and were developed to addrass the educational and developmental needs of children ages 3-5, Typically, these districts are comprised of three types of classes: classes that educate 4-year-old students who have special needs inthe same classroom as those students who do not have special needs; preschool classes for students with Individualized Educational Programs and the need fr smaller groups sizes and more individualized programming; and classes with hight specialized guy Mids autism and students with hearing impairments.When visiting a child care or early learning program, there are questions you can ask to help you determine which program is best for your child and family. These questions are based on indicators of quality that are embedded in the Grow Nu Kids standards. Safe, Healthy Learning Environment Q How many children will be in your Se eee neem. chil ass/group? What ar the between program staffteachers ‘ages ofthe childron in the classroom/ and parents? How isthe information home? communicated (email, phone calls, 4s there adally schedule? letters sent home with child]? Does the dally schedule incorporate Isthe space clean? ‘both indoor and outdoor play ‘opportunities? Do you cbserve positive, warm and nurturing teacher-child interactions ‘and canversatians while in the 2 Doyou see staff and children washing their hands before and after meats and diapering? Is the facility safe and secure? classrooryhome? |. Isthe outdoor play space safe, clean, Do you see children interacting with free of litter and broken glass? each other? (2 What meals ae provided by the _ Dothe children have access to books and other materials? ‘Ae the children read to each day? Does the program use a research based curriculum [age appropriate Does the program havean oral health forinfants and young children}? ora tooth brushing policy? ( Arechildren given “free play” time Does the program check the (For example, are children allowed to children’s eyes, hearing, teeth, and choose the hook tey like tread or ‘rout by providing screenings? what activity they'd tke to do}? prograrn? Are children allowed to bring their own food for religious or ddiotary reasons? oo Does the program support breasteeding (oreast mikstorage Family and Community place to breastfeed? Engagement Q._Are children of ifferent ages cared Joes the program have an open door for together or are they grouped by policy? Are parents allowed to visit at age? anytime? (How are children supervised D._Does the program make coramunity during different situations (sleep or resources fevents, information ‘outside playl? regarding services} available to families? Does the program embrace your chila’s home tanguage in the elassroomfome ander inthe wad ‘materials being used? {Does the program share information ids about actities/essons being worked Nd eee nes For infants is there a daly log? Does the program have opportunities for parents to volunteer in the classroom/home? Does the program offer parent workshops? Does the program have a parent council or parent group? Workforce/Professional Development a Q a What is the education level ofthe staff? How tong have the staff been employed with the program? What types of trainings do staf attend each year? How many staff have received Cardio Pulmonary Resuscitation [CPR] and First Aid training? It the program uses a research-based curriculum, have the staff had formal curriculum training? Administration and Management Q oa Does the program have a current child care ticonse or family child care registration? If applicable, as some ‘school district programs are net required to have a child care license.) What is the tuitionfcost? Other fees? Does the program have a parent handbook that outlines policies and procedures including child iiness/ sickness, emergencies, ciscipline? Is the program director on site during operating hours? What isthe daly child check-in and check-out policy when dropping off ‘and picking up your child? Is the program enrolled in Grow NJ Kids? For parenting resources, vst GrowN JKds.com ht cara Halptine 929227