Annual Household Income
(Approx. 75% SMI) at or below
Monthly Household Income
Your caseworker may ask for a few documents to process your application. However, you have the option of uploading them here to expedite the review of your eligibility determination for SIR child care.
Proof of employment may include your current paystub (dated in last 30 calendar days), Employment verification form signed by your employer, or a signed letter of employment on company letterhead with appropriate company contact information.
If you are not the parent of the child(ren), providing 'In Loco Parentis' documentation would also be helpful. Please see This Document for details.
By signing this document, you agree to the following statements:
I certify that I qualify as a Service Industry Worker, require child care to work, my family income is at or below 75% SMI and the address I have provided is my current residential address. I also certify that I am meeting the participation requirements for my household size (25 hrs. per week for single parent/50 hrs. per week for two-parent household).
I understand that child care is only provided for 12 months and I will have to reapply for child care services at the end of the 12-month timeframe. Upon re-applying I may be subject to a waitlist and will not have child care services while on the waitlist or during the eligibility process.
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.