Arlington Teacher Childcare Assistance Form

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Please complete the following information for parents who are child care employees working at TRS facilities in Arlington.

You will have a chance to review/confirm all information before submitting.

Contact Information
Do you live in Tarrant County?*
- Yes
- No
Physical Address*
Street Address City ZIP Code
Mailing Address*
Street Address City ZIP Code
Is your Mailing Address different?
- Mailing Address is different from Physical Address
Home Phone*
Cell Phone
Work Phone
Email*
Enter Email Confirm Email

Child(ren)
How many people are in your Family?*
Please enter a value greater than or equal to 1.
Please list all of your children and specify if they require child care.*
Please note that any child receiving care must be under the age of 13, a US citizen or legal immigrant, and reside with a family within Tarrant County. Proof of legal guardianship may also be required.
First Name Middle Name Last Name Date of Birth Gender (M/F)

Occupation
Do you currently work at a TRS facility in Arlington?*
- Yes
- No
Employer Name*
Address of Employer*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Based on family size*, is your income** at or below these annual or monthly limits?*
Please select your response.
- Yes
- No

* Family Size consists of those in the home that can be claimed as dependents on a federal tax return or a minor who is the responsibility of the parent/applicant.
** Income does not include federal or state assistance or child support and is your gross income received (before taxes).
State Median Income= SMI

Family Size	Annual Household Income (Approx. 85% SMI) at or below	Monthly Household Income (Approx. 85% SMI) at or below
2	$45,301	$3,775
3	$55,960	$4,663
4	$66,619	$5,552
5	$77,728	$6,440
6	$87,937	$7,328

Review Information and Sign
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By signing this document, you agree to the following statement:*
I am a teacher working at a Texas Rising Star Facility in Arlington. I certify that all information provided on this form is accurate and child care may be terminated if any of this information is found to be inaccurate. I understand that giving false information may constitute fraud and could result in prosecution and/or repayment of money for services for which I was not entitled.
Please type your name in the signature field to sign.
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Arlington Teacher Child Care Assistance Form

Step 1 of 7

Basic Info

Contact Information

Child(ren)

Occupation

Review Information and Sign