Application for Employment Related Day Care (ERDC) Program

Transcription

1 Application for Employment Related Day Care (ERDC) Program Please read these instructions before filling out this application. Answer all questions. Do not write in the shaded areas. To contact our office If you have questions or changes to report, contact our office: Name: Address: Phone: Who should complete this application This application is for the Employment Related Day Care Program (ERDC). It is for child care benefits only. Families seeking cash, food or medical benefits should not use this application. How do I apply for ERDC 1. Complete this application and turn it in to your local office. 2. Give proof of eligibility. 3. Have an interview with a worker in person or by phone. How do I prove eligibility You will need to give proof of your income, work hours and work schedule. The following are examples. Bring or send those that apply to you. Pay stubs or employer statements of gross pay and work hours Copy of work schedule Latest award letter from Social Security or Veteran s Administration Court order stating amount of child support or alimony Records of income from self-employment Last year s tax statement, if self-employed Student Financial Aid Award letter If your child has a disability, you may qualify for a higher child care payment rate. Your child must have a disability that requires extra care. To see if you qualify, you must complete and return a Special Need Child Care Rate Request form (DHS 7486). If your child is older than age 11, you may still qualify for child care help. Your child must meet certain requirements. Talk to your worker to see if you qualify. Applicant rights You have the right to talk to your worker or a person in charge. You have the right to request a hearing if you disagree with the decision on your application. Page 1 of 5

2 Client responsibilities If you get ERDC, you must report the following changes within 10 days of occurrence: Address change; Household income is at or above the amounts shown in this table; A discharged military member returning from active duty in a war zone; The discharged military member becomes employed or returns to active duty; You change or add a new child care provider; Someone moves in or out, including a child, spouse or parent of an unborn child; There is a job loss or you are on medical leave; Someone on work search starts working; Someone returns to work after medical leave; Child care is needed while someone is attending school. You must help the Department of Human Services (DHS) if your case is chosen for review. You must agree to use a child care provider that meets DHS listing requirements. Household Gross monthly size: income: 2 $3,994 3 $4,362 4 $5,089 5 $5,919 6 $6,785 7 $7,652 8 or above $8,519 Our discrimination policy The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not discriminate against anyone. This means that DHS OHA will help all who qualify and will not treat anyone differently because of age, race, color, national origin, gender, religion, political beliefs 1, disability or sexual orientation 2. You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons. To file a complaint with the state, you can call the Governor s Advocacy Office at (TTY 711) or write to their office at: Governor s Advocacy Office 500 Summer Street NE, E17, Salem, OR Fax: [email protected] Equal opportunity is the law! The United States Department of Agriculture (USDA) and the United States Health and Human Services (HHS) a re equal opportunity providers and employers. Auxiliary aids and services are available upon request to individuals with disabilities. To file a complaint with USDA and HHS, please read the Client Discrimination Complaint Information form (DHS 9001). You can find this form in the Information and Referral Packet (DHS 6609). 1 SNAP clients are protected against political belief discrimination. 2 Sexual orientation is protected by the State of Oregon, but not federal laws. Tear off this page and keep it for your records Page 2 of 5

3 Agency use only Branch: Case number: Worker ID: Case name: FILE Application for Employment Related Day Care (ERDC) Program Let us know if you need: c An interpreter Language I speak: c A sign language interpreter c Written materials translated (what language): Materials in: c Braille c Large print c Audio tape c Computer disk c Oral presentation If you are not registered to vote where you live now, would you like to apply to register to vote today? Yes No Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this agency. 1. Name (last, first, middle initial): Other names used: Do you plan to stay in Oregon? c Yes c No Home address: City: State: ZIP code: Home phone number: Mailing address (if different from home address): City: State: ZIP code: Message or work number: 2. List all people living with you, even if you are not applying for them. If you need more room, attach another sheet. *Racial heritage - We ask for this information to help us follow Federal Civil Rights laws. Title VI of the Civil Rights Act of 1964 allows us to do this. You can choose not to give this information. It will not affect your eligibility for services. (Select one or more for each person below) W - White A - Asian I - American Indian/Alaska Native B - Black or african American P - Pacific Islander/Native Hawaiian ** Ethnicity - H - Hispanic/Latino N - Not Hispanic/Latino *** Providing a Social Security number (SSN) is voluntary when applying for ERDC. Self Person 1 Person 2 Person 3 Name (last, first, middle initial): Relation: Self Sex: c Male c Female c Male c Female c Male c Female c Male c Female Date of birth: *Ethnic: c H c NH c H c NH c H c NH c H c NH *Race (circle): B A W I P B A W I P B A W I P B A W I P Purchase and prepare c Yes c No c Yes c No c Yes c No c Yes c No meals with you? U.S. citizen: c Yes c No c Yes c No c Yes c No c Yes c No Want services for this c ERDC c ERDC c ERDC c ERDC person? c SNAP c None c SNAP c None c SNAP c None c SNAP c None ***Social Security number (only for those who want services): Page 3 of 5

4 3. Are you homeless? Yes No Homeless could mean living in an emergency shelter, shared housing with another family because of job loss or loss of your housing, in a motel, car, park, public place, campsite or other similar place. 4. Do you need child care for a foster child? Yes No 5. Do you have shared custody for any of the children needing care? Yes No 6. Do you need child care while you are working and attending classes? Yes No Class hours can only be approved if you are working and attending a school that is eligible for federal financial aid. You must give a copy of your school registration and current class schedule. 7. Are your children s immunization (shot) records up-to-date? c Yes c No If no, contact your doctor or local health department for more information. You must agree to meet state immunization guidelines to get child care benefits. 8. Does anyone have special child care needs? c Yes c No If yes, who? 9. Does anyone work? (Students include work study) c Yes c No If yes, complete below. List each job for each person who works or is self-employed. Attach proof of income received last month and current month. If this is a new job, list date work started: If self-employed, check here c Job #1 Job #2 Job #3 Person working: Employer s name and phone number: Hourly pay: $ $ $ If you are not paid by the hour, explain your income here: Hours (per week): How often paid (weekly, monthly): Pay dates: Tips per week: Draws/overtime pay/bonuses/commissions: $ $ $ Will this income continue? c Yes c No* c Yes c No* c Yes c No* *If income will change, give the reason for the change here: New amount: $ $ $ Date of the change: 10. Please list information about your work schedule and care providers. Usual work hours: From: a.m. / p.m. To: a.m. / p.m. Usual work days: c Mon. c Tues. c Wed. c Thu. c Fri. c Sat. c Sun. Other schedule (describe): Please give proof of your work schedule. This could include a letter from your employer or a copy of your schedule. It must show days worked with your start and end times. Please list information about your child care provider: Provider name Provider phone Percentage of hours for provider 1st 2nd Page 4 of 5

5 11. Does anyone get money from any other source? c Yes c No If yes, complete below. Attach proof. Some examples are: Social Security Interest income Winnings Unemployment compensation Veterans benefits Worker s compensation Student income/money for school Child support Loans/gifts Person 1 Person 2 Person 3 Name of person who received other money: Source of other money: How often paid: Amount of each payment $ $ $ Amount this month: $ $ $ Will this income continue: c Yes c No* c Yes c No* c Yes c No* * If income will change, give the new amount. What is the reason for the change and when it will change? 12. Is anyone a student in college, trade school or other training programs? c Yes c No If yes, attach a copy of your Financial Aid Award Letter. Student 1 Student 2 Name of student: Name of school/ training program: Type of student: Credits: Student last term, this term or both? Apply for or get financial aid? High school GED Graduate Vocational Undergraduate High school GED Graduate Vocational Undergraduate Last term This term Both Last term This term Both Apply Getting Apply Getting 13. Do you need to get away from an abusive situation? c Yes c No I have read the information attached to this application. By signing this application, I swear under penalty of perjury I have given true and complete information. I realize that making false statements or hiding information may subject me to state and federal penalties. I authorize release of my child support records from the Department of Justice (DOJ), Division of Child Support (DCS) to DHS. If you have provided your SSN for other programs, DHS may use your SSN to prepare aggregate information or reports requested by funding sources for the program you apply for or receive benefits from. DHS may use your SSN to conduct quality assessment and improvement activities. Full signature of applicant Date Full signature of spouse or partner Date Agency use only Date of request: Date pended: Date approved: Date denied: Client referred to: c CC Resource & Referral c Headstart c DHS c OHA c APD c VRD c Other: Comments: Page 5 of 5