Cs 925 Form PDF Details

The CS-925 form is a critical document for families in New York City seeking child care assistance through the Administration for Children’s Services (ACS). This comprehensive form is designed to gather detailed information about the applicant's household, employment status, income, and the specific child care needs of the family. It requires applicants to provide personal data, including names (with any aliases or maiden names), addresses, contact numbers, and specifics about each household member, particularly the children for whom care is requested. The form also inquires about public assistance status, Medicaid, primary language, and includes a detailed section for listing the employment information of the guardian or parent applying for child care services. The employment section asks for hours per week, work schedules, and any potential overtime or rotating shifts. Furthermore, it prompts applicants to disclose whether the child care request is primarily for work-related reasons, if the child lives with someone other than their parents, any special conditions the child might have, and whether the child has health insurance. Additionally, the CS-925 form requires a thorough declaration of all household income, necessitating documentation for verification. This aspect ensures that the eligibility for child care assistance is accurately assessed based on the family’s financial situation. The form also allows for the specification of preferred child care providers and the type of care—center-based, family day care, head start, or informal care—that the applicant is considering. Ultimately, by signing the CS-925 form, applicants affirm the accuracy of the information provided and acknowledge the potential legal consequences of falsifying information. This document serves as a pivotal step in the process of obtaining child care subsidy, ensuring that families in need of assistance are able to pursue employment or educational opportunities while securing safe and reliable care for their children.

QuestionAnswer
Form NameCs 925 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesCS-925, RECERTIFICATION, TANF, ACS

Form Preview Example

CS-925 (FACE)

 

 

 

 

 

 

 

 

N

 

 

nyc

REV. 5/07

 

 

 

ACANRCHDCARBDY

 

 

 

RCAN

 

 

 

ACS

 

 

 

 

 

 

 

 

 

Children’s Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NYC Administration for

NNACAA

 

 

 

 

 

 

 

 

 

 

 

RANNACHDCAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CUNY

 

 

Case #:

 

 

 

 

 

 

 

 

Application Date: ______ /______ /______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

Name (Please include any aliases or maiden names in parentheses):

 

R

Name:

 

 

 

 

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

ADDR

Residence:

 

 

 

 

A#

CYBRUH

 

 

A

CD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section ACAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDR

Mailing (if different than above):

 

 

 

A#

CYBRUH

 

 

A

CD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

(Work):

 

N

(Home):

 

 

N

 

 

 

(Cell or Other):

 

 

 

(

) ____________________________________________

(

) ____________________________________________

(

 

 

) ____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you receive PA? Y

N

Do you receive Medicaid? Y

N

What is your primary language?

 

 

 

PA #: __________________________________________

MA #: __________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please fill out the information below for your entire household. List yourself first, followed by everyone who lives with you.

 

 

 

 

 

 

 

Section 2

AY

 

A

Name

 

 

 

 

DOES THIS

BOTH OF CHILD’S

DATE OF

 

HISPANIC

RACE

SOCIAL

 

R

Name

 

RELATIONSHIP

PERSON NEED

PARENTS RESIDE

SEX

OR

(SEE

SECURITY

(PLEASE INCLUDE ANY ALIASES OR

 

BIRTH

 

CHILD CARE?

IN THE HOME?

 

LATINO

LEGEND

NUMBER

MAIDEN NAMES IN PARENTHESES)

 

 

 

 

MM/DD/YY

 

 

 

 

 

YN

YN

 

YN

BELOW)

(OPTIONAL)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RAC

1.Native American or Alaskan Native

2. Asian 3. African American/ Black

4. Native Hawaiian/Pacific Islander

5. Caucasian/ White

 

For additional family members, please attach a separate sheet.

Include information for any spouse/other parent of the children applying for care who lives in the home.

CUNY

Family Size: ______

Section 3

Section 4

Y

CHD

AY

ACANʼY

Name:

 

Hours per week:

 

Tel #:

 

 

 

 

 

 

 

 

 

(

) ______________________________

ADDR

 

CYBRUH

A

CD

 

 

 

 

 

 

 

 

 

 

 

ACANʼ

 

 

 

 

 

 

Y

N

Scheduled Days and Hours of Employment(i.e.: Mon – Fri, 9 a.m. – 5 p.m.):

 

Does Job have a Rotation Shift?

 

 

 

 

Does Job Require O/T?

 

Y

N

UHARY

Name:

 

Hours per week:

 

Tel #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

) ______________________________

ADDR

 

CYBRUH

A

CD

 

 

 

 

 

 

 

 

 

 

 

UHAR

 

 

 

 

 

 

Y

N

Scheduled Days and Hours of Employment(i.e.: Mon – Fri, 9 a.m. – 5 p.m.):

 

Does Job have a Rotation Shift?

 

 

 

 

Does Job Require O/T?

 

Y

N

 

 

 

 

 

 

 

 

 

 

 

Are you requesting child care primarily so that you can work?

Y

N

Is the child for whom you are requesting care living with

 

 

 

If not, please read the instruction section titled “Child/Family Needs” and write your

someone other than his/her mother or father?

Y

N

 

reason for care here:

 

 

Does your child have any conditions that require special help or

 

 

 

 

 

attention?

Y

N

N

___________________________________________________________________________

Does your child have health insurance?

Y

N

OVER

CS-925 (REVERSE)

nyc

ACS

REV. 5/07

Please complete income information for yourself AND anyone applying with you. See instructions for documentation requirements.

NYC Administration for

Children’s Services

(This includes children in need of care, their parents, step-parent and any other children under the age of 18 in household.)

N

Section 5

 

 

 

HNCRNN

 

 

 

 

 

 

 

Section 6

D

 

 

 

 

Section 7

C

 

G R O S S

T Y P E O F

O F F I C E U S E M O N T H LY

I N C O M E

D O C U M E N TAT I O N

C A L C U L AT I O N S

ACAN

Job earnings before deductions.

 

weekly bi-weekly semi-monthly other

UHAR

Job earnings before deductions.

 

weekly bi-weekly semi-monthly other

For all other income/ benefits please itemize below. Include the amount

NC

 

F O R O F F I C E U S E O N LY

for yourself AND your spouse AND child(ren) who live with you.

DCUAN

CACUAN

 

Alimony and/or child support. ci

weekly bi-weekly semi-monthly other

Unemployment and/or worker’s compensation.

weekly bi-weekly semi-monthly other

Net income from self-employment and/or rental income.

weekly bi-weekly semi-monthly other

BSocial Security, SSI, Disability, Retirement and/or Pensions & Annuities.

weekly bi-weekly semi-monthly other

HNCB

(Check All That Apply): Cash or monetary assistance through the Temporary Assistance to Needy Families (TANF) program or Public Assistance (PA).

 

Housing voucher or cash assistance.

Food stamps.

Other federal cash income programs (such as SSI).

ANC

If your child is already in care, or you know the name of the program/provider where you plan to enroll your child, please list the provider name and address below.You may list a second choice.

Name: _____________________________

RA#

Name: _____________________________

RA#

Name: _____________________________

RA#

Address: ___________________________

 

Address: ___________________________

 

Address: ___________________________

 

 

 

 

 

 

 

Please check the types of care that you would consider if there are no available slots with the provider(s) you listed above or if you do not have a provider in mind: Center Based Care Head Start Informal Care Family Day Care

Is/are the child/children for whom you are applying a U.S. citizen(s)? Y N

If Y , Parent/Guardian must sign and date to certify that the child/children in receipt of child care assistance/subsidy _______________________________________ ______ /______ /______

is/are a U.S. citizen(s).

PARENT/CARETAKER/WIFE/HUSBAND

DATE

If No, your eligibility must be determined at the Resource Area (R.A.), please make an appointment at your R.A. and bring the documentation listed in the instructions for this form.

Section 8

I understand that the information contained on this form will be used to determine my or my family’s eligibility for services/subsidy and that the information will only be used for the purposes of determining child care eligibility.

The social security numbers (if provided) will not be released as they are confidential under federal law and can be released/used only for the purposes specified in federal law.

I agree to inform the agency immediately of any change in my income, living arrangement, household composition or address, where care is provided, who is providing child care, provider fees, hours for which child care is needed, and that New

York State Law and Federal Law provides that any applicant may be investigated for fine or jail or both, for a person found guilty of obtaining child care assistance/subsidy by concealing information or providing false information.

I understand that this application is used only for the expressed purpose of child care subsidy. To obtain other assistance such as Food Stamps, Medicaid, Temporary Assistance, or other services, additional applications will be required.

I certify under the penalty of law that all the information I have supplied on this form is true and correct.

CCAN

proiignroprncrrwhoi

pplingrchilcrincorignro

norirprn

 

X __________________________________________________

______ /______ /______

X__________________________________________________

______ /______ /______

NAUR

PARENT/CARETAKER/WIFE/HUSBAND

DATE

NAUR

AUTHORIZED REPRESENTATIVE

DATE

___________________________________________________________________________

______________________________________________________________________________

NNA

 

 

NNA

 

 

9

 

 

Enrollment Applicon Completed by: __________________________ ______ ______ /______ /______

ng

of Eligibility:

from: ______ /______ /______

 

 

 

PRINT AND INITIAL

 

DATE

 

 

 

to: ______ /______ /______

Section

 

 

 

 

 

 

 

C NY

 

ACS – igibili

Approved by: ________________________________ ______ ______ /______ /______

 

 

 

 

 

– Verified by: _______________

______ /______ /______

 

 

 

 

 

 

 

 

PRINT AND INITIAL

 

DATE

 

 

 

 

Parent Fee:

 

______ ______ /______ /______

 

 

PRINT AND INITIAL

DATE

 

 

 

 

 

INITIAL

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

CD

RC

 

 

 

 

 

 

 

 

 

 

 

 

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