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CS-925 (FACE)

nyc

REV. 5/07

ACANRCHDCARBDY

RCAN

ACS

Children’s Services

NYC Administration for

NNACAA

RANNACHDCAR

CUNY

Case #:

Application Date: ______ /______ /______

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

Name:

ADDR

Residence:

CYBRUH

Section ACAN

ADDR

Mailing (if different than above):

CYBRUH

(Work):

(Home):

(Cell or Other):

(

) ____________________________________________

(

) ____________________________________________

(

) ____________________________________________

Do you receive PA? Y

Do you receive Medicaid? Y

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

Name

DOES THIS

BOTH OF CHILD’S

DATE OF

HISPANIC

RACE

SOCIAL

Name

RELATIONSHIP

PERSON NEED

PARENTS RESIDE

SEX

(SEE

SECURITY

(PLEASE INCLUDE ANY ALIASES OR

BIRTH

CHILD CARE?

IN THE HOME?

LATINO

LEGEND

NUMBER

MAIDEN NAMES IN PARENTHESES)

MM/DD/YY

BELOW)

(OPTIONAL)

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

CHD

ACANʼY	Name:			Hours per week:	Tel #:
					(	) ______________________________
ADDR		CYBRUH	A	CD
ADDR		CYBRUH	A	CD
ACANʼ							Y	N
ACANʼ	Scheduled Days and Hours of Employment(i.e.: Mon – Fri, 9 a.m. – 5 p.m.):			Does Job have a Rotation Shift?			Y	N
				Does Job Require O/T?			Y	N
UHARY	Name:			Hours per week:	Tel #:
UHARY	Name:			Hours per week:	Tel #:
					(	) ______________________________
ADDR		CYBRUH	A	CD
ADDR		CYBRUH	A	CD
UHAR							Y	N
UHAR	Scheduled Days and Hours of Employment(i.e.: Mon – Fri, 9 a.m. – 5 p.m.):			Does Job have a Rotation Shift?			Y	N
				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
	reason for care here:			attention?	Y	N
N	___________________________________________________________________________			attention?	Y	N
N				Does your child have health insurance?	Y	N

OVER

	CS-925 (REVERSE)	nyc
	CS-925 (REVERSE)	ACS
	REV. 5/07	ACS
	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: ______ /______ /______
9			PRINT AND INITIAL		DATE				to: ______ /______ /______
Section			PRINT AND INITIAL		DATE
	C NY	ACS – igibili	Approved by: ________________________________ ______ ______ /______ /______
	C NY						– Verified by: _______________			______ /______ /______

			PRINT AND INITIAL		DATE
		Parent Fee:		______ ______ /______ /______				PRINT AND INITIAL		DATE
				INITIAL	DATE
							CD	RC

Question	Answer
Form Name	Cs 925 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	CS-925, RECERTIFICATION, TANF, ACS

Cs 925 Form – Fill Out and Use This PDF

Cs 925 Form PDF Details

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