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CHILD DEVELOPMENT AND CARE (CDC) APPLICATION

State of Michigan

Department of Human Services(DHS)

	FOR DHS USE ONLY
Case Name

Case Number		DHS Specialist

DHS Office			Date

INSTRUCTIONS:  You must live in Michigan.  Your completed and signed application must be received by DHS before eligibility is determined.  Providing your Social Security Number (SSN) is voluntary. If you do provide it, the SSN may be used for establishing identity and for tracking and reporting purposes.

SECTION 1 – APPLICANT INFORMATION

Full name of applicant (First, middle, last)

2. Former/maiden name

3. Marital status

Never Married

Married

Divorced

Separated

Widowed

Authorized representative name (First, middle, last)

5. Authorized representative address

Will the authorized representative be providing care for any of the children on this application?

Yes If yes  Name of child(ren):

Check where you live:

House/apartment/mobile home

Homeless

Other

Address where you live, or address of facility (number, street, rural route, apartment/lot number)

City

State

ZIP code

County

Mailing address (if different from above or PO box)

City

State

ZIP code

County

10. Home phone

11. Cell phone

12. Work phone

13. TTY #

14. Phone number where we can leave a message

Whose is it? (name/relationship)

15. Email address

16. Ethnicity (optional)

17. Race (optional)

Hispanic/Latino

American Indian/Alaska Native – Enter tribe name

Native Hawaiian/Other Pacific Islander

Non-Hispanic/Latino

Asian

Black/African American

White

18. I need child care services for (Check all that apply.)

19. I need study time for (Check all that apply.)

Number of weekly hours

Work

High School or GED Completion

Approved Education/Training/

Approved Education/Training/Employment Preparation

Employment Preparation

Treatment for Health or Social Condition (explain):

SECTION 2 – LIST ALL PERSONS LIVING IN YOUR HOME: (Attach additional sheet if needed.)

					Social Security		Receive cash	Receive
Name	Date of birth	U.S.	Sex	Relationship		Does this person attend school?	assistance
(First, middle, last)		citizen?	(M/F)	to you	Number		benefits	SSI
					(voluntary)			benefit?
							from DHS

No	M		No	Yes	No	No
No	M	SELF	If yes, where and address		No	No
Yes	F	SELF	If yes, where and address		Yes	Yes
Yes	F				Yes	Yes


No	M		No	Yes	No	No
No	M		If yes, where and address		No	No
Yes	F		If yes, where and address		Yes	Yes
Yes	F				Yes	Yes


No	M		No	Yes	No	No
No	M		If yes, where and address		No	No
Yes	F		If yes, where and address		Yes	Yes
Yes	F				Yes	Yes


No	M		No	Yes	No	No
No	M		If yes, where and address		No	No
Yes	F		If yes, where and address		Yes	Yes
Yes	F				Yes	Yes


No	M		No	Yes	No	No
No	M		If yes, where and address		No	No
Yes	F		If yes, where and address		Yes	Yes
Yes	F				Yes	Yes

CONTINUE ON PAGE 2 

DHS-4583 (Rev. 4-12) Previous edition obsolete. MS Word

SECTION 3 – LIST CHILDREN IN YOUR HOME WHO NEED CHILD CARE: (Attach additional sheet if needed.)

Name of child needing care

Provider Name

Provider ID Number

(if known)

SECTION 4 – OTHER INFORMATION: Check all that apply.

I am a foster parent requesting child care only for a foster child(ren).

I need child care only to participate in a required activity for my DHS Protective Services case.

SECTION 5 – INFORMATION ABOUT ALL CHILDREN UNDER AGE 18 WHO LIVE IN YOUR HOME Complete table below. (Attach additional sheet if needed.)

List the full name of

all children under the age of 18 who live in your home (First, middle, last)

Child 1

Child 2

Child 3

Child 4

List full name of each

If the child does

If parent not in the home,

proper box.

child’s mother and

not live with a

Is parent

militarytheIn

Does the parent

father. Write

parent, who does

Married

Divorced

Separated

Prison

Dead

forAbsent reasonother

Parent’s mailing address if

“Unknown” if you do

living

the child live with

provide child

in the

different from the applicant.

not know who the

and the

support?

home?

mother or father is.

relationship to

(First, middle, last)

the child?

Mother	Name		No	Yes
No		If yes, provide
Yes	Relationship	support # if known


Father	Name		No	Yes
No		If yes, provide
Yes	Relationship	support # if known
Yes	Relationship

Mother			No	Yes
Mother	Name		No	Yes
No		If yes, provide
Yes	Relationship	support # if known


Father	Name		No	Yes
No		If yes, provide
Yes	Relationship	support # if known
Yes	Relationship

Mother			No	Yes
Mother	Name		No	Yes
No		If yes, provide
Yes	Relationship	support # if known


Father	Name		No	Yes
No		If yes, provide
Yes	Relationship	support # if known
Yes	Relationship

Mother			No	Yes
Mother	Name		No	Yes
No		If yes, provide
Yes	Relationship	support # if known


Father	Name		No	Yes
No		If yes, provide
Yes	Relationship	support # if known
Yes	Relationship

CONTINUE ON PAGE 3 

DHS-4583 (Rev. 4-12) Previous edition obsolete. MS Word

SECTION 6 – SELF-EMPLOYMENT ONLY – List anyone in your home who is self-employed including yourself. Attach current

proof. (Attach additional sheet if needed.)

		Business			Gross monthly	Date of most
Self-employed		Business		Hours of self-	income (amount	Date of most
Self-employed	Start date	name/address/	Type of work	Hours of self-	income (amount	recent or last
person	Start date	name/address/	Type of work	employment	before any	recent or last
person		phone number		employment	before any	pay check
		phone number			expenses)	pay check
					expenses)
				Mon

				Tue

				Wed	$

				Thur
				Thur

				Fri

				Sat


		Business			Gross monthly	Date of most
Self-employed		Business		Hours of self-	income (amount	Date of most
Self-employed	Start date	name/address/	Type of work	Hours of self-	income (amount	recent or last
person	Start date	name/address/	Type of work	employment	before any	recent or last
person		phone number		employment	before any	pay check
		phone number			expenses)	pay check
					expenses)
				Mon

				Tue

				Wed	$

				Thur
				Thur

				Fri

				Sat

SECTION 7 – EMPLOYMENT INCOME – List anyone in your home with any earnings including yourself. Attach current proof. (Attach additional sheet if needed.)

Name of working person

Start date

Employer name/address/

phone number

Type of work

Job Title

Work schedule

Hours

Mon

Tue

Wed

Thur

Fri

Sat

Sun

If new job, first pay check date

Will employment continue?

Yes

Day of week pay is received

Most recent or last pay check date

Average number of hours expected to work

Rate of pay

per

Week

Pay period

Hourly

Salary

Other

How often are checks received?

Weekly

Every two weeks

Twice a month

Monthly

Other

Do you receive any of the following?

Do you work Overtime?

Bonus

Commission

Yes

 If yes, amount

How often?

Do you receive tips not included in your check?

Yes

 If yes, average tips not included $

Per

Week

Pay period

Other

CONTINUE ON PAGE 4 

DHS-4583 (Rev. 4-12) Previous edition obsolete. MS Word

Question	Answer
Form Name	Dhs 4583 Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	CDC, DHS-4583, Michigan, SSN

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