How To Get A Child Care License In The United States
|
|
|
- Nathan Butler
- 5 years ago
- Views:
Transcription
1 WORKFORCE SOLUTIONS CHILD CARE SERVICES Child Care Services (CCS) Parent Self-Employment Packet SECTION I: BUSINESS INFORMATION (Complete this section if you own your own business. TWIST ID: Name of Business: EIN, ITIN or SSN for Business Owner: Start Date of Business: Name of Owner: Business Phone: Number of Employees: Physical Address of Business: Rent Own Did you file income taxes for your business last year? Yes If you did not file income taxes last year, please explain: Do you have documentation that verifies the amount of hours worked each week? Yes Explain how hours are calculated: If applicable, how do you pay other employees? Cash Check How many employees? Do you maintain a business ledger? Yes If so, provide a copy. Does an auditor or bookkeeper verify your business records? Yes SECTION II: INDEPENDENT CONTRACTOR (SELF-EMPLOYED) INFORMATION Complete this section if you are paid in cash or by check and are not deducted any Income Tax, Social Security or Medicare Tax TWIST ID: Name of Business: EIN, ITIN or SSN for Business Owner: Start Date of Business: Name of Contractor: Business Phone: Number of Employees: Physical Address of Business: Rent Own Did you file income taxes for your business last year? Yes If you did not file income taxes last year, please explain: Do you have documentation that verifies the amount of hours worked each week? Yes Explain how hours are calculated: If applicable, how do you pay other employees? Cash Check How many employees? Do you maintain a business ledger? Yes If so, provide a copy. Does an auditor or bookkeeper verify your business records? Yes Customer Signature: Date: disabi lities Relay Texas: (TTY); (Voice); (Espanol) 1 Page
2 SECTION II: SELF-EMPLOYMENT OVERVIEW Background: CCS families are responsible for providing sufficient documentation to CCS for eligibility determination. CCS will use your adjusted business income for eligibility purposes. Your adjusted business income is your net income after business expenses are deducted. In order for an expense to be deductible, the business expense must be both ordinary and necessary. An ordinary expense is one that is common and accepted in your field of business, trade, or profession. A necessary expense is one that is helpful and appropriate for your business, trade, or profession. Types of Self-Employment: New Self-Employment is defined as a parent that started an income-producing enterprise in the current calendar year and tax records are not available at the time of application. Sustained Self- Employment is defined as a parent that operated and continues to operate an income-producing enterprise dating back to the previous calendar year. For the purpose of child care eligibility, parents will be classified as self-employed if their wage records do not reflect at least one of the following deductions: federal income tax withholding, Social Security or Medicare taxes. Work Hours: CCS families are required to work an average of 25 hours per week for a single- parent household, or a combined 50 hours per week for a 2-parent household. CCS staff will calculate the amount of hours worked per week based on the net monthly income, the net income will be divided by the current minimum wage hourly rate to determine eligibility. Business Records: You will be required to attach clear and legible business records that support the information reported. Supporting documentation includes but is not limited to: invoices, work orders, customer contracts, tax records, list of customer contacts, cancelled checks that have been processed by your bank, and business receipts that support expenses and income for your business. You may be required to provide additional documentation after your case has been reviewed for eligibility. Fraud: Providing false documents for eligibility purposes is considered fraud and will result in termination and/or denial of services. All suspected fraud will be investigated and is subject to termination of your child care services, recoupment and criminal prosecution. References: You may reference Internal Revenue Service (IRS) Publications 535 and 583 for further guidance on proper book keeping practices and allowable deductions for your business Or you may contact the IRS with your tax questions at Page
3 Additional Resources: Employer/Employee Tax Information Texas Workforce Commission (956) Information on Visas, Work Permits, Passports, Matricula, etc. Consulate of Mexico (956) Information on EIN (Employer Identification Number) Internal Revenue Service (800) Information on ITIN (Individual Tax Identification Number) Internal Revenue Service (800) Small Business Administration Rio Grande Valley SCORE E. Tyler Ave. Suite E Harlingen, Texas (956) SECTION III: SELF-EMPLOYMENT DOCUMENTATION REQUIREMENTS Acceptable Documentation for Verification of Self-Employment Status One of the following forms of documentation will be required for initial verification of established self-employment enterprises: Federal income tax forms or quarterly income reports, such as: o Form 1040; or o Schedule C, F, or SE federal income tax returns for the most recent tax year; One of the following documentations can be used to document the existence of the business: O Property titles, deeds, or rental agreement for the place of business; o Recent business bank, phone, utility, or insurance bill; or o Recent state sales tax return. o Amounts received; and Acceptable Documentation to Determine Income Eligibility for Child Care Services The following documentation will be required to determine income eligibility for child care services: Documentation that provides information on the amount of income generated and the associated business expenses and contains: o Customer names and contact information (if available); o Dates and locations of services provided; o Amounts received; and Business expense receipts that substantiate the expenses to be deducted from the gross income, when applicable. 3 Page
4 SECTION IV: INSTRUCTIONS FOR ATTACHMENT A: BUSINESS INCOME STATEMENT Include month of operation on each Business Income Statement. Date: Enter the date of the transaction. Business Expenses: Provide an explanation for the amount that was paid out by the business. For example, you may enter bought lawn mower. Amount: The amount of the business expense. Receipts required for deduction. Income Source: Provide explanation for the source of income. For example, you may enter Cut grass John Moore 1234 Main Avenue McAllen, Texas. Gross: This is the amount of payment you received for goods or services. Receipts needed and ledgers may be accepted for payment you received for certain goods or services. Adjusted Business Income: Enter the net amount after business expenses are deducted from gross income. Your eligibility will be based on this amount. Print name, sign, date, and include TWIST ID on all Business Income Statements. 4 Page
5 Attachment A: Business Income Statement Business Income Statement for month of: Date Business Expenses Amount Date Business Income Amount Total Business Income $ Total Business Expenses $ Total Business Expenses Adjusted Business Income $ te: Adjusted Business Income = Total Business Income minus Total Business Expenses Please attach Section 1: Business Information and documentation for verification of self employment to this statement along with payment receipt and expense receipt( if applicable). The above information is true, correct and complete to the best of my knowledge. I understand that giving false information to the CCS contractor could result in my case being disqualified and prosecuted for fraud. Print Name Date Signature TWIST ID Business Income Statement
UPMC Financial Assistance Application Information
UPMC Financial Assistance Application Information UPMC offers financial assistance for medical care provided by UPMC facilities and UPMC affiliated physicians to eligible individuals and families. Based
2014 Tax Organizer. Thank you for taking the time to complete this Tax Organizer.
2014 Tax Organizer This Tax Organizer is designed to help you collect and report the information needed to prepare your 2014 income tax return. The attached worksheets cover income, deductions, and credits,
Application form completely filled out and signed.
x INTERIOR REGIONAL HOUSING AUTHORITY Tribal Equity Advantage Mortgage (TEAM) Program 828 27 th Avenue i Fairbanks, Alaska 99701 Phone: (907) 452-8315 i Fax: (907) 452-8324 Applicant Name: Date of Application:
VILLAGE REHAB PROGRAM
I N T E R I O R R E G I O N A L H O U S I N G A U T H O R I T Y 8 2 8 2 7 T H A v e n u e F a i r b a n k s, A l a s k a 9 9 7 0 1 P h o n e : ( 9 0 7 ) 1-8 0 0-4 7 8-4 7 4 2 F a x : ( 9 0 7 ) 4 5 2-8
CHILDCARE ASSISTANCE PROGRAMS PARENT AND PROVIDER GUIDE
CHILDCARE ASSISTANCE PROGRAMS PARENT AND PROVIDER GUIDE Ramsey County Community Human Services and Think Small Contents Customer Service Standards What child care programs are available? Who should you
CHIP Health Insurance Renewal Form
CHIP Health Insurance Renewal Form 1. Household Information. First: MI: Last: Suffix: Head of Household : Street: Apt #: Address: Phone: City: State: Zip: Email: Primary: Alternate: Best time to call:
Immigration and Taxation
Immigration and Taxation Immigration, Employment and Tax Laws Why do immigrants without status pay taxes? Obligated by law Opportunity to contribute Document compliance and residency Immigration, Employment
2015 2016 Verification Worksheet Independent Student- Group 6
Student Financial Services 1200 East Colton Avenue, Redlands, CA 92373-0999 Telephone: (909) 748-8047 Email: [email protected] Fax: (909) 335-5399 Web site: www.redlands.edu/financialaid.asp 2015 2016 Verification
NEED HELP? CALL TOLL FREE AT 1-888-690-0985
Public Partnerships, LLC Financial Administration Services 6 Admiral s Way Chelsea, MA 02150 Phone 1-888-690-0985 TTY 1-800-360-5899 Administrative Fax 1-866-254-9729 [email protected] Dear Employer:
BELOW MARKET RATE HOME OWNERSHIP PROGRAM APPLICATION PACKET
BELOW MARKET RATE HOME OWNERSHIP PROGRAM APPLICATION PACKET Applicant Household Qualifications Below Market Rate Home Ownership Program QUALIFICATION STANDARDS AND PROGRAM REQUIREMENTS The following table
New Client Start-up Checklist
New Client Start-up Checklist Thank you for choosing LowCostPayroll.com as your payroll service provider. In order to set your company up on our payroll system we need some information. Please review the
Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage
Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage CHIP CHIP covers children from birth through age 18 who do not qualify for Medicaid
*Please read before filling out rental application*
*Please read before filling out rental application* Make sure the following three (3) items accompany your rental application or application will not be processed. Application fee There is a non-refundable
2015 Senior Emergency Safety Grant
2015 Senior Emergency Safety Grant The program is designed to address immediate health and safety deficiencies at your home. Final determination of necessary improvements will be made by the Housing Programs
LIVE NEWARK DEPARTMENT OF ECOMONIC AND HOUSING DEVELOPMENT DIVISION OF HOUSING AND REAL ESTATE HOME FACADE PROGRAM (HFP) APPLICATION
LIVE NEWARK DEPARTMENT OF ECOMONIC AND HOUSING DEVELOPMENT DIVISION OF HOUSING AND REAL ESTATE HOME FACADE PROGRAM (HFP) APPLICATION Please PRINT and complete ALL pages of this application in its entirety
201% through 225% of FPG. 226% through 250% of FPG. 75% Adjustment. 50% Adjustment
Charity Care Policy/Procedure Patient Financial Services Policy 10 Revised February 2014 Purpose: Wyoming Medical Center prides itself in being a responsible member of this community. Our commitment to
What to Expect: Your Guide to Affordable Housing
What to Expect: Your Guide to Affordable Housing NYC Housing Connect: Steps to Apply [FRONT] What does it mean for housing to be affordable? A common rule is that housing is considered affordable when
Instructions for AHCCCS Health Insurance Application and Forms. Verification and Documentation Choosing a Health Plan
Instructions for AHCCCS Health Insurance Application and Forms Understanding the AHCCCS Eligibility Process AHCCCS Application Verification and Documentation Choosing a Health Plan Instructions for AHCCCS
Tax Planning and Reporting for a Small Business
Table of Contents Welcome... 3 What Do You Know? Tax Planning and Reporting for a Small Business... 4 Pre-Test... 5 Tax Obligation Management... 6 Business Taxes... 6 Federal Income Tax Forms... 7 Discussion
Health Reimbursement Account (HRA) Frequently Asked Questions
Health Reimbursement Account (HRA) Frequently Asked Questions Q. What is a Health Reimbursement Account (HRA)? A. A Health Reimbursement Account (HRA) is part of the benefit plan offered to you by Brookhaven
Instructions to fill out this Application
Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage CHIP CHIP offers health care for children, from birth to age 18, whose families
Renewal Form. www.upmchealthplan.com/upmcforkids
Renewal Form www.upmchealthplan.com/upmcforkids There are three easy ways to renew CHIP coverage! To keep CHIP coverage, you can: 1. RENEW ONLINE USING COMPASS: (If you apply online, most of your information
D Approved for Exemption on: D 60% of value but not less than $60,000. D Approved for Refund by Assessor: D Aooroved for Refund by Treasurer:
Senior Citizen and Disabled Persons Exemption from Real Property Taxes Chapter 84.36 RCW Complete both sides of this form and file the application packet with your County Assessor. For assistance, contact
b Issued by document (ID) 31 Total price if different from item 29 $.00
IRS Form 8300 (Rev. August 2014) Department of the Treasury Internal Revenue Service Report of Cash Payments Over $10,000 Received in a Trade or Business See instructions for definition of cash. Use this
2015-2016 Independent Verification
V6- IND FORM 2015-2016 Independent Verification Your 2015-2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called Aggregate Verification. Northern is required
2015-2016 Dependent Aggregate Verification
V5- DEP FORM 2015-2016 Dependent Aggregate Verification Your 2015-2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called Aggregate Verification. Northern is required
PERSONAL FINANCIAL WORKSHEET
PERSONAL FINANCIAL WORKSHEET This is NOT the Personal Financial Statement required for DBE certification and cannot be substituted for the mandatory Personal Financial Statement. This document is intended
Identity Protection Services
Identity Protection Services Overview Why are identity protection services being provided? We believe your personal information should stay that way personal. That s why we re taking industry- leading
Self Employed & Single Member LLC Tax Organizer
Self Employed & Single Member LLC Tax Organizer CLIENT INFORMATION Business Name (DBA): Email: Date of Formation: EIN#: Best Phone#: Business Address: Tax Period City: State: ZIP Code: What date was the
Consumer Guide for Annual Household Income Data Matching Issues
Consumer Guide for Annual Household Income Data Matching Issues This is a guide to help you understand how the Marketplace uses annual household income to decide whether you qualify for help paying for
2015-2016 Household V1-Veri ication Worksheet McMurry University
2015-2016 Household V1-Veri ication Worksheet Your 2015-2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says that before awarding
Health Benefits for Workers with Disabilities Application
Illinois Department of Public Aid Health Benefits for Workers with Disabilities Application Note: This is NOT an application for cash assistance, food stamps or enrollment in the Medicaid spenddown program.
There are other Medicaid programs that require a different application from this one.
MEDICAID APPLICATION FOR Qualified Medicare Beneficiaries (QMB) Specified Low Income Medicare Beneficiaries (SLIMB) Qualified Individuals 1 (QI) Working Disabled Individuals (WDI) INFORMATION FOR THE APPLICANT
Collection Information Statement for Wage Earners and Self-Employed Individuals
Form 433-A (Rev. December 2012) Department of the Treasury Internal Revenue Service Collection Information Statement for Wage Earners and Self-Employed Individuals Wage Earners Complete Sections 1, 2,
Client Start-up Checklist
Client Start-up Checklist Adding clients to Intuit Online Payroll for Accounting Professionals is easy! Just gather some basic client information listed in step 1, set up your client s payroll account
South Dakota Application for Medicare Savings Program
DSS-EA-270 10/15 South Dakota Application for Medicare Savings Program NOTE: This application CAN be used for a single person or a couple (self and spouse). If you want more information on the following
Georgia Department of Human Services Georgia Senior Supplemental Nutrition Assistance Program (SNAP) Application
Georgia Department of Human Services Georgia Senior Supplemental Nutrition Assistance Program (SNAP) Application This application is used for individuals applying for the Supplemental Nutrition Assistance
UNITED STATES DISTRICT COURT for the District of
Page 1 of 5 UNITED STATES DISTRICT COURT for the District of Plaintiff/Petitioner v. Civil Action No. Defendant/Respondent APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Long
RICE COUNTY ENVIRONMENTAL SERVICES RICE COUNTY SUBSURFACE SEWAGE TREATMENT SYSTEM LOW INCOME FIXUP GRANT PROGRAM
(507) 332-6113 RICE COUNTY ENVIRONMENTAL SERVICES 320 Northwest Third Street Suite 9 Faribault, Minnesota 55021-6145 Toll free from Northfield (507) 645-9576 Toll free from Lonsdale (507) 744-5185 TDD
2015-2016 Dependent Verification
V6- DEP FORM 2015-2016 Dependent Verification Your 2015-2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. Northern must compare information
ST. CLAIR HOSPITAL CHARITY CARE FINANCIAL ASSISTANCE PROGRAM QUALIFYING GUIDELINES
Page 1 of 10 CHARITY CARE FINANCIAL ASSISTANCE PROGRAM QUALIFYING GUIDELINES Charity Care is granted to patients whose credit score is less than the hospital's current threshold of 0. Program guidelines
9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof.
Dear Parent/Guardian: Children need healthy meals to learn. Your child s school offers healthy meals every school day. Your childr en may qualify for free meals or for reduced price meals. 1. DO I NEED
FSE/VENDOR F/EA PAYROLL PROCESS
FSE/VENDOR F/EA PAYROLL PROCESS Vendor Fiscal/Employer Agents (F/EAs) operate under Section 3504 of the IRS code (Appendix A), and Revenue Procedure 70-6 (Appendix B). IRS Proposed Notice 2003-70 (Appendix
State of Wisconsin Department of Revenue Wisconsin Homestead Credit Situations and Solutions
State of Wisconsin Department of Revenue Wisconsin Homestead Credit Situations and Solutions Publication 127 (02/15) Table of Contents I. INTRODUCTION... 3 II. SITUATIONS AND SOLUTIONS... 3 A. Situations
Broker. Owning, Managing and Supervising a Real Estate Office. Chapter 3. Copyright Gold Coast Schools 1
Broker Chapter 3 Owning, Managing and Supervising a Real Estate Office 1 Learning Objectives List at least 6 categories of costs required when establishing a brokerage office List the 3 factors a broker
(V1) Independent Student Standard Verification Group 2015-2016
Dear Student, You have been selected for the Verification Process which requires the college to confirm information that you entered on the (FAFSA). The Federal Department of Education requires specific
Not Knowing How To Manage the Pieces will Cost You Money
Not Knowing How To Manage the Pieces will Cost You Money 1 Table of Content Section Page Executive Summary 3 Your Responsibilities 4 Employee Taxes 5 Employer Taxes 6 Social Security Tax 7 Medicare Tax
2015 2016 Verification Worksheet for Independent Student
2015 2016 Verification Worksheet for Independent Student Your 2015 2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says that before
Tax Resolution Underwriting Worksheet
Tax Resolution Underwriting Worksheet Office: Tax Consultant: Date: Personal Information Spouse info Taxpayer's name DOB SSN Filing Status (SINGLE, JOINTLY, SEPARATELY) Address Home Phone Number Cell Phone
Small Business Startup Guide
Small Business Startup Guide By Carol Topp, CPA [email protected] 10288 Amberwood Ct Cincinnati, OH 45241 (513)777-8342 This short guide is intended to help an individual start his or her own business.
Page 1 GUARANTOR APPLICATION FOR LEASE
Page 1 GUARANTOR APPLICATION FOR LEASE WILLIAMSBURG PROPERTY MANAGEMENT, INC. 811 RICHMOND ROAD/WILLIAMSBURG, VA 23185 (757)229-8292 - PH (757)229-2943 - FAX E-MAIL: [email protected] The property will
WE CAN HELP YOU! DTE ENERGY OFFERS A LOW INCOME SELF- SUFFICIENCY PLAN (LSP)
WE CAN HELP YOU! DTE ENERGY OFFERS A LOW INCOME SELF- SUFFICIENCY PLAN (LSP) This program allows you to make affordable monthly payments based on your income. The remaining portion of your bill is paid
Information Handbook. www.uimn.org. What you need to know about Unemployment Insurance. October 26, 2014 through October 24, 2015
What you need to know about Unemployment Insurance October 26, 2014 through October 24, 2015 www.uimn.org Apply for benefits, request benefit payments, check your account online or by phone Monday through
METHOD A ENROLLMENT FEE WAIVER
California Community Colleges 2015-16 Board of Governors Fee Waiver Application This is an application to have your ENROLLMENT FEES WAIVED. If you need money to help with books, supplies, food, rent, transportation
Georgia DBHDD NOW & COMP Waiver Programs. For Self-Directing Participants
Public Partnerships, LLC Georgia DBHDD NOW & COMP Waiver Programs 5660 New Northside Drive Suite 450 Atlanta, Georgia 30328 Toll Free Numbers Phone: 1-866-836-6792 TTY System: 1-800-360-5899 Administrative
ELECTRONIC TAX FILING TAX PREPARATION PACKET
CUBE TAX SERVICE ELECTRONIC TAX FILING and TAX PREPARATION PACKET "Once a Client - Always a Client" Visit us at our website www.cubetax.com If you have any questions, contact CUBE TAX SERVICE 512.833.7856
Career Goals 0 points Activities 0 points
Directions for Completing the Scholarship Application READ DIRECTIONS CAREFULLY I. General Instructions for all applicants 1. Must be completed by applicant; 2. Must be typewritten or legibly printed in
GOVERNMENT OF THE DISTRICT OF COLUMBIA OFFICE OF THE CHIEF FINANCIAL OFFICER OFFICE OF TAX AND REVENUE OFFER IN COMPROMISE. Form OTR-10 Booklet
GOVERNMENT OF THE DISTRICT OF COLUMBIA OFFICE OF THE CHIEF FINANCIAL OFFICER OFFICE OF TAX AND REVENUE OFFER IN COMPROMISE Form OTR-10 Booklet Content What is an Offer in Compromise (OIC)? What is the
Terraces at Lawson Creek Resident Selection Criteria
Property Name: Terraces at Lawson Creek Resident Screening and Selection Process Terraces at Lawson Creek Thank you for applying to live within our community. Quantum Management Services, Inc. is an Equal
IDAHO CHILD CARE PROGRAM (ICCP)
IDAHO CHILD CARE PROGRAM (ICCP) Dear Customer, In order to process your application for Child Care Assistance in the most efficient and timely manner possible, we will need to verify certain items. We
Documentation Needed for Rehabilitation Program:
Documentation Needed for Rehabilitation Program: 1. Completed and Signed Home Rehabilitation Application (7 pages) 2. 2 Current Tax Returns (must sign 2 nd page), for everyone over 18 in household with
Number, street, and room or suite no. If a P.O. box, see the instructions. City or town, state or province, country, and ZIP or foreign postal code
Form 1065 Department of the Treasury Internal Revenue Service A Principal business activity U.S. Return of Partnership Income For calendar year 2015, or tax year beginning, 2015, ending, 20. Information
2015 2016 Verification Worksheet Independent Student
2015 2016 Verification Worksheet Independent Student Your 2015 2016 Free Application for Federal Student Aid (FAFSA) may be selected for review in a process called verification. The law says that before
Small Business Tax Issues
Small Business Tax Issues Presenter: Julie Herman-Wiese Business Development Manager H&R Block and Fill in tax preparer [email protected] 253.656.1379 Prior to H&R Block: Ran my own consulting
City of Miami Department of Community Development Florida Homebuyer Opportunity Program
City of Miami Department of Community Development Florida Homebuyer Opportunity Program The City s Florida Homebuyer Opportunity Program (FLHOP) provides assistance of up to $8,000 to income eligible homebuyers.
Financial Statement for. Self-Employed People
Financial Statement for Self-Employed People Ben SE August 2010 About this form Please fill in this form if: you or your partner are self-employed AND you are not sending any business accounts with your
WHAT YOU MUST DO TO RECEIVE UNEMPLOYMENT BENEFITS
Rev. 01/2014 Office of Unemployment Insurance Administration Unemployment Claims Unit PO Box 94094, Room 386 Baton Rouge, Louisiana 70804-9096 Unemployment Benefits Rights and Responsibilities (Benefits
To see if you qualify for this program, send the items listed below to Northwest Savings Bank.
COMPLETE YOUR CHECKLIST We need this information to help you modify your mortgage payment. To see if you qualify for this program, send the items listed below to Northwest Savings Bank. 1. The enclosed
NANNYCHEX PO Box 4276 Greenwood Village, CO 80155 303-770-5570 1-877-626-6924 [email protected] www.nannychex.com
Your 2014 Nanny Tax and Insurance Obligations SOCIAL SECURITY AND MEDICARE TAXES (FICA) Employer s and Nanny s Expense You are required to withhold Social Security and Medicare taxes when you pay a household
APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS
APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS 1. Please read the enclosed brochure for important information. 2. You may use this application to apply for Special Care for adults
How To Fill Out A Federal Loan Rehabilitation Form
RAP FINANCIAL DISCLOSURE FOR REASONABLE AND AFFORDABLE REHABILITATION PAYMENTS William D. Ford Federal Direct Loan (Direct Loan) Program Page 1 of 5 OMB No. 1845-0120 Form Approved Exp. Date 03/31/2017
SECTION 15 (HIPAA-CHIP) ELIGIBILITY AND ENROLLMENT FORM COMPLETE ALL OF THE FOLLOWING QUESTIONS IN THEIR ENTIRETY (Please print)
I C H I P Illinois Comprehensive Health Insurance Plan STATE OF ILLINOIS COMPREHENSIVE HEALTH INSURANCE PLAN (CHIP) 400 West Monroe Street, Suite 202, Springfield, Illinois 62704-1823 1-866-851-2751 (toll-free
Crime Victim Compensation
Crime Victim Compensation Eighth Judicial District Crime Victim Compensation 201 LaPorte Avenue Ste 200 Fort Collins CO 80521 970-498-7290 www.larimer.org/da/vicwit/compensation.htm APPLICATION The Victim
Application for Benefits
Application for Benefits If you need help reading or completing this form, please ask us for help. Keep this page for your records. How do I apply for benefits? To complete your application fill out pages
2. It is a requirement that you submit proof of ALL income for yourself and spouse/significant other for the past 3 months.
Dear Child Care Client: Enclosed is a Child Care Assistance Application information packet. Please read the entire packet carefully so that you will understand and comply with all requirements, thus ensuring
Preparing For Your Unemployment Insurance (UI) Audit
Preparing For Your Unemployment Insurance (UI) Audit This page describes the preparation, expectations, and results of an Unemployment Insurance (UI) Audit. INTRODUCTION This page addresses the most frequently
Name Date. Address Phone. Household Size (City) (State) (Zip) How long have you lived in Louisa County? Where did you live before? How long?
1 LOUISA COUNTY COMMUNITY SERVICES 117 S. Main St., PO Box 294 Wapello, Iowa 52653 General Assistance Application Phone 319-523-5125 Name Date Address Phone (Street) (P.O. Box) Household Size (City) (State)
Retina Consultants of Southern Colorado, P.C. Financial Hardship Packet
Retina Consultants of Southern Colorado, P.C. Financial Hardship Packet Patient Name: Date: Please complete the Financial Hardship packet and return to our patient accounts department within 10 days. Packets
Application for Bond Loan and Rental Grant assistance
Office use only (application number) Bond Loan Rental Grant Application for Bond Loan and Rental Grant assistance The Department of Housing and Public Works provides Bond Loans and Rental Grants to people
Kansas Department for Children and Families Grandparents as Caregivers Cash Assistance Application
Kansas Department for Children and amilies Grandparents as Caregivers Cash Assistance Application ollow These Steps to Apply Agency Use Only Initial Review ES-3100.9 Rev. 7-12 Complete this form or go
Apply for Free and Reduced Price Meals OR Prepay for Meals Online!
Stafford County Public Schools Apply for Free and Reduced Price Meals OR Prepay for Meals Online! Dear Parent/Guardian, Stafford County Public Schools Is pleased to announce the availability of applying
APPLICATION PROCESS FOR CITY OF VIRGINIA BEACH BUSINESS LICENSE
APPLICATION PROCESS FOR CITY OF VIRGINIA BEACH BUSINESS LICENSE Determine the business entity type. Corporation, Limited Liability Company, General or Limited Partnership? No Yes Sole Proprietorship or
P E N N S Y L V A N I A
P E N N S Y L V A N I A Application for Payment of Medicare Premiums, Coinsurance and Deductibles If you have a disability and need this form in large print or another format, please call our helpline
