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Section 7
Provider
If you qualify for Child Care Assistance funded by the New York State Child Care Block Grant, you have the option to choose: center-based or home-based child care. If you choose a provider that is not licensed or registered, the provider must be
enrolled as a Legally-Exempt provider. Provide below the name(s) and address(es) of your choice of provider(s). You may list additional choices on an attached sheet.
Name:
Program #
(if applicable)
: Name:
Program #(if applicable)
: Name:
Program #(if applicable)
:
Address: Address: Address:
Section 8
Certifi ation
1. I understand that the information contained on this form will be used to
determine my or my family’s eligibility for services/subsidy. I understand
that by signing this application form, I agree to cooperate fully with any
investigation to verify or conrm the information I have given or any other
investigation in connection with my request for child care assistance. I will
provide additional information if requested.
2. Social Security Numbers, if provided, may be used by federal, state, and
local agencies to prevent duplication of services, fraud and for federal
reporting.
3. I agree to inform the agency immediately of any change in my needs, income,
address, living arrangement, household composition or address where care
is provided, who is providing child care, provider fees and/or hours for which
child care is needed.
4. I certify that the children indicated as needing child care are United States (U.S.)
citizens, U.S. nationals, or persons with satisfactory immigration status.
I understand that this information about these children may be submitted to the
Immigration and Naturalization Service (INS) for verication of immigration status, if
applicable. I further understand that the use or disclosure of this information about
these children is restricted to persons and organizations directly connected with the
verication of immigration status and the administration or enforcement of provisions of
the Child Care Assistance Program.
5. I understand that this application is used only for the expressed purpose of child care
assistance. To obtain other assistance such as SNAP, Medicaid, Cash Assistance, or
other services, additional applications will be required. However, this application and
any information obtained as part of an investigation of this application may be shared
with any City, State or Federal agency to which you apply or have applied for any other
assistance or benets.
6. Federal and state laws provide for penalties of ne, imprisonment or both if you do not tell
the truth when you apply for Child Care Assistance, or when you are questioned about your
eligibility, or if you cause someone else not to tell the truth regarding your application or
continuing eligibility. Penalties also apply if you conceal or fail to disclose facts regarding your
initial or continuing eligibility for Child Care Assistance; or if you conceal or fail to disclose
facts that would affect the right of someone, for whom you have applied, to obtain or continue
to receive Child Care Assistance. If you are the authorized representative applying on behalf
of someone else, Child Care Assistance must be used for that person and not yourself. It
is unlawful to obtain Child Care Assistance by concealing information or providing false
information.
7. I certify that my family resources do not exceed $1,000,000.00.
It is the policy and commitment of the New York City Administration for Children’s Services that it does not discriminate on the basis of race, creed, age, color, sex, religion, national origin, alien-age or citizenship status,
physical or mental disability, gender, gender identity, sexual orientation, pregnancy, marital or partnership status.
You may obtain information on your rights and responsibilities at http://otda.ny.gov/programs/applications/4148A.pdf
If you do not have access to the Internet, you can call NYC ACS at (212) 835-7610 to request physical copies of the following booklets.
LDSS-4148A: What You Should Know About Your Rights and Responsibilities; LDSS-4148B: What You Should Know About Social Services Programs; LDSS-4148C: What You Should Know If You Have an Emergency
Certifi ation: I swear and/or afrm under the penalties of perjury that all of the information I have given or will give to NYC ACS relating to Child Care Assistance is correct. I have read and understand the notices both above
and attached. I understand and agree to the above-listed certications.
Please provide the signatures of both parents/caretakers if two parent/caretaker household.
Signature Parent/Caretaker: Signature Parent/Caretaker: Signature Parent/Caretaker:
Print Name: Date: Print Name: Date: Print Name: Date:
Section 9
Ofce Only
Authorized Days and Hours of Care:
Authorized Days and Hours of Care for Second Shift/Work/Activity Schedule
(Complete only if parent provides second shift/work/activity schedule in Section 5)
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
from to from to from to from to from to from to from to
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
from to from to from to from to from to from to from to
Eligibility determined and approved by (print and initial): Date:
Length of Eligibility from to Codes: RFC: PR: FS: