CFWB-012
REV. 07/23
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Application For Child Care Assistance
Please read instructions (CFWB-012A) and review the document checklist (CFWB-012B) for assistance when completing this and for information on what documents are required.
ATTENTION: This application is used to apply only for Category 2 or 3* child care assistance (for families not in receipt of cash assistance). To apply for Cash Assistance or other benets,
including Category 1 Child Care Assistance (for families in receipt of cash assistance), you must use the New York State Application for Certain Benets and Services (LDSS-2921).
Please Note: All sections of this form must be lled out to be considered complete
unless the section is identied as optional. If you do not complete all required
sections of this form, you may not be considered for Child Care Assistance.
OFFICE USE ONLY Case #: Application Date:
Section 1 - Applicant
Last Name (Please include any aliases or maiden names in parentheses): First Name: M.I.: Marital Status:
Home Address: Apt. #: City/Borough: State: ZIP Code:
Is this a temporary address?
Yes
No
If yes, does family currently reside in
(check one):
Homeless Shelter
Doubled-up with another family
Hotel/Motel
Car, Bus, Train
Park, Campsite
Other
Telephone (Work): Telephone (Home): Telephone (Cell or Other): Email:
Do you receive Cash Assistance?
Yes
No CA#: What is your primary language?
English
Spanish
Other
What is your preferred language?
English
Spanish
Other
Please list all children in your household needing child care. (Only children needing care)
Section 2
Child(ren) Needing Care
Name (Last, First) M.I. Relationship D.O.B.
Gender
Both of Child’s
Parents Reside
in the Home?
Ethnicity
Hispanic or
Latino**
Race**
(See legend
below)
Social
Security
Number
(Optional)
Child with a
Disability?
Is child U.S. Citizen/
U.S. National/ or person
with satisfactory
immigration status?
1.
2.
3.
4.
5.
6.
7.
8.
The following applicants may be eligible for child care assistance without regard to income and do not need to complete this application:
Foster parents who need child care assistance to allow them to work and are only applying for assistance for the foster child(ren).
Families in receipt of protective or preventive services.
Refer to application instructions (CFWB-012A) for details
New
Change/Recertication
Reopen
* Category 1: Families eligible for a child care guarantee – applying for or receiving
Cash Assistance (CA), or receiving Child Care Assistance in lieu of
CA or receiving transitional child care
Category 2: Families eligible when funds are available
Category 3: Families eligible when funds are available and ACS has included them
in its Child and Family Services Plan
** Providing ethnicity and race information is voluntary and will
not affect your eligibility for Child Care Assistance or the
amount of assistance that you will be given by this agency.
Racial Afliation Codes:
AI Native American or Alaskan Native
AS Asian
BL Black or African American
HP Native Hawaiian or Pacic Islander
WH White
CLEAR
SAVE
CFWB-012
REV. 07/23
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Please list all other members in your entire household (not listed in Section 2A) including children under age 18 who do not need child care. List yourself rst, followed by everyone who lives with you.
Section 2B
Family Members
Name ( Last, First) (Include any aliases or maiden names in parentheses) M.I. Relationship D.O.B.
Gender
Ethnicity
Hispanic or
Latino**
Race**
(See legend
to the right)
Social Security
Number (Optional)
1.
Self
2.
3.
4.
5.
6.
7.
8.
Section 3
Child/Family Needs
What is your reason for requesting Child Care Assistance? Is a parent currently active duty (full-time) in the US Military? Is the applicant receiving and/or applying for child care through a different application?
Employment
Yes
No
If yes please indicate the agency:
Vocational Training/Educational Activities
Department of Education (DOE)
Receiving Domestic Violence Services
Human Resources Administration (HRA)
Looking for Work
Homelessness
Is a parent currently a member of a National Guard or Military Reserve Unit?
Department of Youth and Community Development (DYCD)
Participating in an approved substance abuse treatment program
Yes
No
Department of Homeless Services (DHS)
Is there a non-custodial parent available to provide child care?
Consortium for Worker Education (CWE)
Yes
No
Administration for Children's Services (ACS)
Section 4 - Employment
(if employment is reason for care)
For additional family members, please attach
a separate sheet. Include information for any
spouse, parent or caretaker of the children
applying for care who lives in the home.
Racial Afliation Codes:
AI
Native American or Alaskan Native
AS Asian
BL Black or African American
HP Native Hawaiian or Pacic Islander
WH White
OFFICE USE ONLY Family Size:
Applicants Employer Name: Tel #: Address: City/Borough: State: ZIP Code:
Employment Start Date: Does job have a rotating shift?
Yes
No
Does job require overtime (OT)?
Yes
No
If applicant has a second job
Applicants Employer Name: Tel #: Address: City/Borough: State: ZIP Code:
Employment Start Date: Does job have a rotating shift?
Yes
No
Does job require overtime (OT)?
Yes
No
Second parent, caretaker or stepparent in the household
Applicants Employer Name: Tel #: Address: City/Borough: State: ZIP Code:
Employment Start Date: Does job have a rotating shift?
Yes
No
Does job require overtime (OT)?
Yes
No
If second parent, caretaker or stepparent in the household has a second job
Applicants Employer Name: Tel #: Address: City/Borough: State: ZIP Code:
Employment Start Date: Does job have a rotating shift?
Yes
No
Does job require overtime (OT)?
Yes
No
CFWB-012
REV. 07/23
OFFICE USE ONLY
3 of 7
Section 5
Work/Activity/Travel Time Schedule
Typical work/activity schedule (i.e., educational/vocational activity) Please complete the schedule below only if the parent has a second shift, job or activity
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
from to from to from to from to from to from to from to
Typical work/activity schedule for second parent, caretaker or stepparent in the household
Please complete the schedule below only if the second parent, caretaker or stepparent in the
household has a second shift, job or activity
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
from to from to from to from to from to from to from to
Travel Time Drop off: Travel time from the child care provider to work/activity?
Check one of the following:
15 minutes
30 minutes
45 minutes
1 hour
More than 1 hour. Amount of time if more than 1 hour Public Transportation?
Yes
No
Pick-up: Travel time from work/activity to the child care provider?
Check one of the following:
15 minutes
30 minutes
45 minutes
1 hour
More than 1 hour. Amount of time if more than 1 hour Public Transportation?
Yes
No
Spouse/Other Parent: Travel time from the child care provider to work/activity?
Check one of the following:
15 minutes
30 minutes
45 minutes
1 hour
More than 1 hour. Amount of time if more than 1 hour Public Transportation?
Yes
No
Pick-up: Travel time from work/activity to the child care provider?
Check one of the following:
15 minutes
30 minutes
45 minutes
1 hour
More than 1 hour. Amount of time if more than 1 hour Public Transportation?
Yes
No
Indicate if you or anyone who is applying with you receives money from the following sources. See checklist (CFWB-012B) for documentation requirements. PLEASE PRINT
Section 6
Income Information
Sources Yes /No
Gross
Amount
How often? (weekly,
biweekly, monthly, etc?)
Who is the recipient?
Type of
Documentation
Monthly
Calculations
Applicant Wages/Salary, including overtime, commissions, training programs, tips $
Self
Second parent, caretaker or stepparent in the household Wages/Salary, incl. overtime, commissions, training programs, tips $
Net Self-Employment Income $
Child Support Payments (received) $
Alimony/Spousal Support (received) $
Unemployment Insurance Benets, Workers’ Comp $
Social Security Benets (including SSI) $
Disability Benets (NYS, VA, Private) $
Rental/Boarder/Lodger Income (received) $
Dividends/Interest – Stocks, Bonds, Savings $
Retirement, Pensions/Annuities $
Cash Assistance (CA) Grant, Safety Net Benets $
Other (please specify): $
Total Income $
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
0.00
CFWB-012
REV. 07/23
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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 conrm 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 verication 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
verication 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 benets.
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 afrm 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 certications.
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:
CFWB-012
REV. 07/23
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Please list all children in your household needing child care. (Only children needing care)
Section 2
Child(ren) Needing Care
Name (Last, First) M.I. Relationship D.O.B.
Gender
Both of Child’s
Parents Reside
in the Home?
Ethnicity
Hispanic or
Latino**
Race**
(See legend
below)
Social
Security
Number
(Optional)
Child with a
Disability?
Is child U.S. Citizen/
U.S. National/ or person
with satisfactory
immigration status?
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26
27.
28.
* Category 1: Families eligible for a child care guarantee – applying for or receiving
Cash Assistance (CA), or receiving Child Care Assistance in lieu of
CA or receiving transitional child care
Category 2: Families eligible when funds are available
Category 3: Families eligible when funds are available and ACS has included them
in its Child and Family Services Plan
** Providing ethnicity and race information is voluntary and will
not affect your eligibility for Child Care Assistance or the
amount of assistance that you will be given by this agency.
Racial Afliation Codes:
AI Native American or Alaskan Native
AS Asian
BL Black or African American
HP Native Hawaiian or Pacic Islander
WH White
Additional Children (if applicable)
CFWB-012
REV. 07/23
6 of 7
Please list all other members in your entire household (not listed in Section 2A) including children under age 18 who do not need child care. List yourself rst, followed by everyone who lives with you.
Section 2B
Family Members
Name ( Last, First) (Include any aliases or maiden names in parentheses) M.I. Relationship D.O.B.
Gender
Ethnicity
Hispanic or
Latino**
Race**
(See legend
to the right)
Social Security
Number (Optional)
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26
27.
28.
For additional family members, please attach
a separate sheet. Include information for any
spouse, parent or caretaker of the children
applying for care who lives in the home.
Racial Afliation Codes:
AI
Native American or Alaskan Native
AS Asian
BL Black or African American
HP Native Hawaiian or Pacic Islander
WH White
OFFICE USE ONLY Family Size:
Additional Family Members (if applicable)
7 of 7
CFWB-012
REV. 07/23
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:
Provider
Name:
Program #
(if applicable)
: Name:
Program #(if applicable)
: Name:
Program #(if applicable)
:
Address: Address: Address:
Provider
Name:
Program #
(if applicable)
: Name:
Program #(if applicable)
: Name:
Program #(if applicable)
:
Address: Address: Address:
Provider
Name:
Program #
(if applicable)
: Name:
Program #(if applicable)
: Name:
Program #(if applicable)
:
Address: Address: Address:
Provider
Name:
Program #
(if applicable)
: Name:
Program #(if applicable)
: Name:
Program #(if applicable)
:
Address: Address: Address:
Additional Providers (if applicable)
Income Notes
CFWB-012A Instructions
REV. 07/23
Page 1 of 5
Dear Parent(s)/Caretaker(s),
THIS APPLICATION IS USED TO APPLY ONLY FOR CHILD CARE ASSISTANCE AS A CATEGORY 2 OR 3 FAMILY
If you are applying only for category 2 or 3 Child Care Assistance (for families not in receipt of cash assistance), you can use
this shorter application. If you want to apply for other benefits such as Cash Assistance, Supplemental Nutrition Assistance
Program (Food Stamps), Home Energy Assistance, Medicaid or other services, including category 1 Child Care Assistance (for
families in receipt of cash assistance), please ask for the New York State Application for Certain Benefits and Services (LDSS-2921).
By submitting the Application for Child Care Assistance instead of the New York State Application for Certain Benefits and
Services (LDSS-2921), you are applying for Child Care Assistance only in categories 2 and 3, i.e., when funds are available. You
are not applying in category 1, guaranteed child care.
The following instructions are provided to assist you in completing your application. When completing your application,
please remember to print clearly in block capital letters (A, B, C) using blue or black ink. Alternatively, you may complete the
form electronically, save it, and print it.
This Application must include supporting documentation such as proof of income, proof of address, and proof of employment.
SEE THE ATTACHED SUBMISSION CHECKLIST (CFWB-012B) FOR ALL REQUIRED DOCUMENTS.
READ BEFORE COMPLETING APPLICATION
If you receive preventive or protective child welfare services or you are an employed foster parent you may already be
eligible for child care assistance and may not need to complete this application. Ask your case planner to make a referral for
Child Care Assistance.
If you receive cash assistance (CA), you should contact your Human Resources Administration (HRA) JOB Center for child
care assistance.
PLEASE NOTE: If any required fields are left unanswered, the entire application will be considered incomplete.
OFFICE USE ONLY
Gray shaded boxes are for office use only. Please do not write anything in these sections.
* Category 1: Families eligible for a child care guarantee – applying for or receiving Cash Assistance (CA), or receiving Child Care Assistance in
lieu of CA or receiving transitional child care
Category 2: Families eligible when funds are available
Category 3: Families eligible when funds are available and ACS has included them in its Child and Family Services Plan
Division of Child and Family Well-Being
Instructions for Completing your Application for
Category 2 or 3 Child Care Assistance*
The availability of Child Care Assistance is dependent on funding from the Child Care Block Grant.
If there is no available funding, your child(ren) may be placed on the waiting list.
CFWB-012A Instructions
REV. 07/23
Page 2 of 5
Please indicate at the top right whether you are submitting a new application, requesting a change of status/recertification,
or requesting to reopen your case.
SECTION 1 APPLICANT
The applicant is the adult parent or caretaker requesting care. Unless otherwise noted, this section must contain the following
information about the applicant only:
1. Print your Last and First Name, and middle initial. Please put any aliases or maiden names in parentheses.
2. Indicate your marital status (single, married, divorced or widowed).
3. Print your Home Address.
4. Indicate if address is temporary. Check “YES” only if the family is currently living in a homeless shelter, doubled-up with
another family, in a hotel/motel, in a car/ bus/ train, in a park/campsite, or other.
5. Print your Telephone Numbers, including area code – work, home, and cellular/other (if applicable).
6. Print your e-mail address (optional).
7. Check “YES” or “No” for Cash Assistance Status. (If you are a CA recipient, you should apply for child care through your
Human Resources (HRA) Job Center worker).
8. Check the box for the language that is spoken most often in your household. If other, print the name of the language.
9. Check the box for the language you prefer to communicate in. If other, print the name of the language.
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for New York City Residency.
SECTION 2A CHILDREN NEEDING CARE
1. Print the last and first name, and middle initial of each child in the household for which you are applying for child care assistance.
2. For each child in the household, print their relationship to you (e.g. child).
3. Print the date of birth and check the box indicating the sex for each child listed.
4. Indicate whether both of the child’s parents live in the home.
5. Check YES”or “NO to indicate if each child applying is Hispanic or Latino or not. Providing ethnicity information is voluntary
and will not affect your eligibility for Child Care Assistance or the amount of assistance that you will be given by this agency.
6. Fill in the Race column for each child in need of child care.You may choose multiple race categories for a single child.
Providing race information is voluntary and will not affect your eligibility for Child Care Assistance or the amount of
assistance that you will be given by this agency.Please use the codes below.
AI - Native American or Alaskan Native AS - Asian BL - Black or African American
HP - Native Hawaiian or Pacific Islander WH - White
7. Provide each child’s Social Security Number (SSN). You are not required to provide SSNs. They may be used by federal,
state, and local agencies to prevent duplication of services and fraud, and for Federal Reporting.
8. Check “YES” or “NO to indicate whether the child needing child care has a disability
1
. If your child is determined eligible for
child care assistance, please go to http://www1.nyc.gov/site/acs/early-care/forms.page to obtain a Special Needs Application.
9. CheckYES”or”NO”to indicate whether the child needing child care is a U.S. citizen, U.S. national or person with satisfactory
immigration status.
10. Attach a separate sheet for additional children (if you are requesting care for more than eight (8) children).
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for citizenship/immigration status only for
the child(ren) needing child care.
1
A child with a disability or special needs is a child incapable of caring for himself or herself and who has been diagnosed as having one or more of the follow-
ing conditions to such a degree that it adversely affects the child’s ability to function normally: visual impairment, deafness or other hearing impairment, ortho-
pedic impairment, emotional disturbance, mental retardation, learning disability, speech impairment, health impairment, autism or multiple handicaps. Any
such diagnosis must be made by a physician, licensed or certified psychologist or other professional with the appropriate credentials to make such a diagnosis.
CFWB-012A Instructions
REV. 07/23
Page 3 of 5
SECTION 2B FAMILY MEMBERS
1. A family member is any other member in your entire household, including children who do not need child care. List yourself
first, followed by everyone else who lives with you including child’s second parent, caretaker and stepparent if applicable.
Caretaker includes legal guardian, caretaker relative or any other person in loco parentis to the child. Print last and first
name, and middle initial if applicable.
2. Print each persons relationship to you (e.g. spouse, partner, grandparent, parent, etc.).
3. Print the date of birth and and check the box indicating the sex for each person in the household.
4. Check “YES” or “NO to indicate if each member in the household is Hispanic or Latino or not. Providing ethnicity
information is voluntary and will not affect your eligibility for Child Care Assistance or the amount of assistance that you will
be given by this agency.
5. Fill in the Race column for everyone who lives with you. You may choose multiple race categories for a single person.
Providing race information is voluntary and will not affect your eligibility for Child Care Assistance or the amount of
assistance that you will be given by this agency. Please use the codes below.
AI - Native American or Alaskan Native AS - Asian BL - Black or African American
HP - Native Hawaiian or Pacific Islander WH - White
6. Fill in the Social Security Number (SSN) for your family members. SSN is optional. SSN may be used by federal, state, and
local agencies to prevent duplication of services and fraud, and for Federal Reporting.
7. If there are more than eight (8) household members, attach a separate sheet to list all their information.
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for all children in the household under age 18,
regardless if child care is needed for the child, to verify the child’s relationship to the parent/applicant and to verify the
child’s age.
SECTION 3 CHILD/FAMILY NEEDS
1. Please check the appropriate box(es) to indicate your reason(s) for requesting child care assistance.
• Employment
Vocational training, or educational activities
• Receiving Domestic Violence Services
• Looking for Work
• Homelessness
Participating in an approved substance abuse treatment program
2. Check “YES” or “NO” to indicate whether there is a non-custodial parent available to provide child care.
3. Check the appropriate box to indicate whether a parent is currently active full-time in the U.S. Military. You must check
”YES” or “NO” for the application to be complete.
4. Check the appropriate box to indicate whether a parent is currently a member of a National Guard or Military Reserve Unit.
You must check”YES” or “NO” for the application to be complete.
5. Indicate whether the applicant is receiving and/or applying for child care through a different agency and select the agency.
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for each reason for care. Documentation of
military status is not required. An applicant must provide documentation of income received from their military duty.
CFWB-012A Instructions
REV. 07/23
Page 4 of 5
SECTION 4 EMPLOYMENT
(Complete for each employed parent, caretaker or stepparent in the household if your reason for requesting child care
assistance is employment or you are reporting income from employment)
1. Print the applicant’s employer name, address, and telephone number.
2. Print the employment start date.
3. Check the appropriate box to indicate whether your job has a rotating shift and/or requires overtime.
4. If applicable, print the employer name, address and telephone number for second parent, caretaker or stepparent in the
household.
5. If applicable, print the employment date of second parent, caretaker or stepparent in the household.
6. If applicable, check the appropriate box to indicate whether the second parent, caretaker or stepparent in the household has a
rotating shift and/or requires overtime.
DOCUMENTATION: See checklist (CFWB-012B) for documentation required for employment.
SECTION 5 WORK/ACTIVITY/TRAVEL TIME SCHEDULE
(Complete for each parent, caretaker or stepparent in the household who is employed or has an educational/vocational activity)
1. Print the typical scheduled work or activity hours for each day of the week. Indicate if hours are AM or PM.
2. If there is a second shift, job, or activity, print the schedule for that activity.
3. If applicable, print the typical scheduled work hours for each day of the week for the second parent, caretaker or stepparent
in the household.
4. If the second parent, caretaker, or stepparent in the household has a second shift, job, or activity, print the schedule for
that activity.
5. Check the time it takes for the applicant to travel to and from work/activity to provider.
6. Indicate if the applicant uses public transportation to travel to and from work/activity to provider.
7. If applicable, check the time it takes for the second parent, caretaker, or stepparent in the household to travel to and from
work/activity to provider.
8. Indicate if the second parent, caretaker or stepparent in the household uses public transportation to travel to and from
work/activity to provider.
SECTION 6 INCOME INFORMATION
For this section, answer only items for which you or a household member has earned income. Please include income/benefits
information for yourself and any other adult household members including your spouse who lives with you,or an adult who
lives with you and with whom you have a least one child in common. Also include any person under the age of 18 who is
legally responsible for the child or children for whom child care assistance is sought.
1. Check () Yes or No for yourself and anyone who lives with you for each kind of income.
2. For each “Yes” answer, PRINT the dollar ($) amount or value, how often it is received, and the name of the person who gets
the income.
3. All income must be reported on the application.
4. If you indicate receipt of cash assistance, you should apply for child care through your HRA Job Center worker.
5. If you are unsure where to list a type of income, you may include it under other.
DOCUMENTATION: See checklist (CFWB-12B) for documentation required for income.
CFWB-012A Instructions
REV. 07/23
Page 5 of 5
SECTION 7 PROVIDER
1. 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.
2. If you know the provider/program where you would like to enroll your child please indicate the name, address, and ACS
program number (if applicable).
SECTION 8 CERTIFICATION
Please read the certification section carefully and sign. If the applicant is completing the application for someone else, they
must sign their own name. If two-parent household, both parents must sign the application.
By signing, you certify that your combined family resources do not exceed $1,000,000. Examples of family resources are: cash,
savings and checking accounts, your home, real estate, cars, stocks, bonds, mutual funds, IRAs, 401(k), annuity, trust fund, life
insurance, safe deposit box contents, etc.
SECTION 9 FOR OFFICE USE ONLY
Do not complete this section. Staff who are determining your family’s eligibility for care will use this.
VOTER REGISTRATION INFORMATION
The last page of the Application for Child Care Subsidy is an application to register to vote. If you would like help filling out the
voter registration application form, call 311. Applying to register or declining to register to vote will not affect your eligibility
for child care assistance or the amount of assistance that you will be given by this agency.
RIGHTS AND RESPONSIBILITIES INFORMATION
You may obtain information about 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
booklets which highlight your Rights and Responsibilities be mailed to you.
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
Child Care Assistance New Application Submission Checklist
The Application for Child Care Assistance (CFWB-012) must include supporting documentation.
Check to ensure that documentation is provided for each requirement of subsidy eligibility.
1.
APPLICATION (CFWB-012)
Ensure all sections are completed, including:
If two-parent household, both parents signed
Military status (Section 3)
Travel time (Section 5)
2.
NEW YORK CITY RESIDENCY
Copy of one of the following:
IDNYC
Utility Bill (should be current, within 30 days)
Section 8 Award Letter
Drivers License
Rent Receipt or Lease (rent receipt should be current, within 30 days)
NYCHA Certicate
CFWB-067 Residency Attestation
Other
PLEASE NOTE: If “OTHER” documentation is not satisfactory, ACS will notify applicant.
3.
ONLY FOR CHILD(REN) NEEDING CHILD CARE: CITIZENSHIP/IMMIGRATION STATUS
Copy of one of the following:
US Birth Certicate
Alien Registration Card including Permanent Resident or Green Card
US Passport Form
FS-240 (Report of Birth Abroad of a U.S. Citizen)
Naturalization Certicate
Other
PLEASE NOTE: If “OTHER” documentation is not satisfactory, ACS will notify applicant.
4.
CHILD’S RELATIONSHIP TO PARENT/APPLICANT
Copy of one of the following for all children in the household under age 18, regardless if child care is needed for the child:
Birth Certicate
Adoption record
Baptismal record
Court order for legal guardian with nancial responsibility
Passport with parent signature
5.
AGE
Copy of one of the following for all children in the household under age 18, regardless if child care is needed for the child:
Birth Certicate
Adoption record
Baptismal record
Alien Registration Card
Passport
6.
INCOME
All Applicants submitting CFWB-012 must provide documentation of income regardless of reason for care.
If Employed:
CFWB-015 - Referral to Employer for Employee Income Information
OR
Pay Stubs (Bi-weekly = Every 2 weeks; Semi-monthly = Twice a month)
Weekly – 4 current, consecutive pay stubs if gross amount is the same
Weekly – 12 current, consecutive pay stubs if gross varies
Bi-weekly/Semi-monthly – 2 current, consecutive pay stubs if gross amount is the same
Bi-weekly/Semi-monthly – 6 current, consecutive pay stub if gross varies
Please go to https://www1.nyc.gov/site/acs/early-care/forms.page page for forms and application instructions.
For more information call 311 or 212-835-7610.
CFWB-012B
REV. 07/23
1 of 2
If Self-Employed:
If self-employed 1 year or more: current, complete and signed income tax package (ex. 1040, 1065,
Schedule C, SE for partnership, K-1, etc.)
If self-employed less than 1 year, complete and submit CFWB-031 Self-Employment Income
Information Attestation
Other Income:
Recent checks, pay stubs or current award letters required for other income identied by the
applicant on the CFWB-012 including SSI, SSD, unemployment benets, rental income, pensions,
annuities, worker’s compensation, alimony, and child support.
7.
REASONS FOR CARE
Applicant must document one of the following reasons for care:
a. Working minimum of 10 hours per week earning at least minimum wage:
See above under income for required documents regarding Employment and / or Self-employment.
b. Educational/Vocational activity:
Vocational School, 2 Year College, or 4 Year College (one of the following)
CFWB-005 with School’s stamp
A letter from the training or educational institution on ofcial letterhead is also acceptable,
but must contain all necessary information reected on the CFWB-005.
c. Looking for Work (One of the following):
CFWB-026 - Work Search Record
Approved Work Search Plan from the NYS Dept. of Labor
Proof of receipt of Unemployment Insurance
d. Homeless (One of the following):
Written Referral from Hotel/Shelter
CFWB-027 Housing Questionnaire/Attestation
e. Domestic Violence Referral (From Domestic Violence service provider):
Referral for services in response to domestic violence
f. Substance Abuse Treatment Program Referral (From Substance Abuse Treatment service provider):
Referral for services to treat substance abuse
Please go to https://www1.nyc.gov/site/acs/early-care/forms.page page for forms and application instructions.
For more information call 311 or 212-835-7610.
2 of 2
CFWB-012B
REV. 07/23
The City of New York
Administration for Children's Services
Division of Child and Family Well-Being
66 John Street, 7
th
Floor
New York, New York 10038
How to Submit Your Application
Please complete the Application for Child Care Assistance (CFWB-012) collect all required
documentation to verify family size, residency, income, and reason for care. Make sure to use
the application checklist to ensure your application is complete before submitting.
Once complete, please send your application and documentation to the address below for
processing:
NYC Children EDU
PO Box 40
Maplewood, NJ 07040
All documents should be sent by US Postal Service. Documents cannot be sent by Fedex or
UPS to a PO Box.
If you have questions about the application, please call the ACS Child Care Call Center at 212-
835-7610.
MEMORANDUM
To: All Parents/Guardians Applying for Child Care Assistance
Re: Immigration Status
________________________________________________________
CERTAIN PROGRAMS REQUIRE PROOF THAT YOUR CHILD
NEEDING CHILD CARE IS A U.S. CITIZEN, U.S. NATIONAL OR
PERSON WITH SATISFACTORY IMMIGRATION STATUS.
YOU
WILL NOT BE ASKED FOR THE IMMIGRATION STATUS FOR
YOURSELF OR ANYONE ELSE IN THE HOUSEHOLD OTHER THAN
THE CHILD(REN) IN NEED OF CHILD CARE.
If y
ou have any questions or to obtain a list of subsidized early
care and education programs that do not require proof of a
child’s citizenship or immigration status, please call the ACS Child
and Family Well-Being Hotline at (212) 835-7610 or go to our
website at http://www1.nyc.gov/site/acs/early-
care/eligibility.page.
66 John Street/8
th
Floor
New York, New York 10038
Child.FamilyWellBeing@acs.nyc.gov
www.nyc.gov/acs
“If you are not registered to vote where you live now, would you
like to apply to register here today?
Important!
Applying to register or declining to register to vote will not affect the
amount of assistance that you will be provided by this agency.
If you would like help lling out the voter registration application form,
we will help you. The decision whether to seek or accept help is yours.
You may ll out the application form in private.
YES
NO because I choose not to register OR
I am already registered at my current address OR
I asked for and received a mail registration form
If you checked YES, please complete the
VOTER REGISTRATION APPLICATION below
If you do not check
any box, you will
be considered to
have decided not
to register to vote
at this time.
Información en español: si le interesa obtener ee formulario en español,
llame al 1-800-367-8683
中文資料:若您有興趣索取中文資料表格,請電: 1-800-367-8683
한국어: 한국어 한국어 양식을 원하시면 1-800-367-8683
으로 전화 하십시오.
1-800-367-8683

Signature Date
Please Print Name
/ /
Are you a U.S. citizen?
If you answered NO, do not complete this form
A) Will you be 18 years old on or before election day?
B) Are you at least 16 years of age and understand that you must be 18
years of age on or before election day to vote, and that until you will
be eighteen years of age at the time of such election your registration
will be marked “pending” and you will be unable to cast a ballot in any
election?
If you answered NO to both of the prior questions, you cannot register to vote.
YES NO
For Board Use Only
Last Name First Name Middle Initial Sufx
Address where you live (do not give P.O. box) Apt. No. City/ Town/ Village Zip Code County
Address where you get your mail (if different than above) P.O. Box, Star Route, etc. Post Ofce Zip Code
Date of Bir th Gender (optional) Telephone (optional) Email (optional)
The last year you voted Your address was (give house number, street and cit y)
In county/state Under the name (if different from your name now)
ID Number (Check the applicable box and provide your number)
New York State DMV number
Last four digits of your Social Security number
I do not have a New York State DMV or Social Security number
Afdavit: I swear or af rm that
I am a citizen of the United States.
I will have lived in the county, city or village for at least 30 days before
the election.
I will meet all requirements to register to vote in New York State.
This is my signature or mark on the line below.
The above information is true, I understand that if it is not true, I can be
convicted and ned up to $5,000 and/or jailed for up to four years.
Signature or Mark in ink Date
/ /
NYS Agency-Based Voter Registration Form
VOTER REGISTRATION APPLICATION (instructions on back)
Yes, I need an application for an Absentee Ballot Please print or type in blue or black ink Yes, I would like to be an Election Day worker
Last Name
(Optional) Register to donate your organs and tissues
First Name
Address
Birth Date
Middle Initial Sufx
City/ Town/ Village
Apt Number
Zip Code
By signing below, you certif y that you are:
16 years of age or older
Consent to donate all of your organs and tissues for
transplantation, research, or both;
Authorizing the Board of Elections to provide your name and
identif ying information to NYS Donate Life Registry for enrollment;
And authorizing the Registry to allow access to this information to federally regulated
organ procurement organizations and NYS-licensed tissue and eye banks and others
approved by the NYS Commissioner of Health hospitals upon your death.
Signature
Date
/ /
1
3
4
5
6
10
11
2
7 8
9
12
Gender
Eye Color Height
M F
Ft. In.
Democratic party
Republican party
Conservative party
Working Families party
Other
Political Party
I wish to enroll in a political party
I do not wish to enroll in any political party and wish to be an independent voter
No party
Email
DMV or ID NYC Number
YES
NO
YES NO
Qualifications for Registration
You Can Use This Form To:
• register to vote in New York State;
• change your name and/or address, if there is a change since you
last voted;
• enroll in a political party or change your enrollment;
• pre-register to vote if you are 16 or 17 years of age.
To Register You Must:
• be a U.S. citizen;
• be 18 years old (you may pre-register at 16 or 17 but cannot vote until you
are 18);
• be a resident of the County, or of the City of New York at least 30 days
before an election;
• not be in prison for a felony conviction;
• not claim the right to vote elsewhere; and
• not found to be incompetent by a court.
Important!
If you believe that someone has interfered with your right to register or
to decline to register to vote, your right to privacy in deciding whether to
register or in applying to register to vote, or your right to choose your own
political party or other political preference, you may file a complaint with:
NYS Board of Elections
40 North Pearl St, Suite 5
Albany, NY 12207-2729
Telephone: 1-800-469-6872;
TDD/TTY users contact the New York State Relay at 711;
or visit our web site - www.elections.ny.gov
Your decision to register will remain confidential and will be used only for
voter registration purposes. Anyone not choosing to register to vote and/
or information regarding the office to which the application was submitted
will remain confidential, to be used only for voter registration purposes.
Verifying your identity
We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver ID
number), or the last four digits of your social security number, which you will fill in Box 9.
If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement,
paycheck, government check or some other government document that shows your name and address. You may include
a copy of one of those types of ID with this form.
If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.
To complete this form:
It is a crime to procure a false registration or to furnish false information to the Board of Elections.
Box 9: You must make one selection. For questions refer to Verifying your identity above.
Box 10: If you have never voted before, write “None. If you can’t remember when you last voted, put a question mark (?).
If you voted before under a different name, put down that name. If not, write “Same.
Box 11: Check one box only. Political party enrollment is optional but that, in order to vote in a primary election of a political
party, a voter must enroll in that political party, unless state party rules allow otherwise.
Rev. 05/0 4/2021