DSS Form 3791 at a glance
What it is: DSS Form 3791 (SEP 11) is the South Carolina Department of Social Services Child Care Application for the ABC Child Care Program.
Who signs: Signature of Parent/Caretaker.
What to bring and attach to DSS Form 3791
Attach copies of paystubs for the last 4 weeks, or a letter from your employer on company letterhead that shows your gross pay and hours worked for the last 4 weeks; this information must also be provided for your spouse or your child's second parent if in the home.
If you attend school or a training program, attach a copy of the schedule and proof of paid registration for the term during which you are applying for services; this information must also be provided for your spouse or your child's second parent if in the home.
If you are self-employed, attach your most recent income tax forms.
A filled-in DSS Form 3791 example: a single parent applies for child care
How to fill out DSS Form 3791, box by box
Tell us who you are and where you live
Tell who you are and where you live: Last Name, First Name, Mid. Initial, Social Security Number, Gender, Residence Address, City, State, Zip and Birthdate.
Enter the Mailing Address, City, State and Zip if different than the residential address.
Enter the CHIP Case No. if applicable, select the County you live in, and enter the E-Mail and the Home, Work and Cell numbers.
Race, Family Composition, Marital Status and Educational Level
For Race, check Yes or No for each race listed; for Family Composition, Marital Status and Educational Level, select one.
For Ethnicity, check Yes or No for Hispanic/Latino.
Sources of Income
Under Sources of Income, check Yes or No for each source (Employment, Housing Voucher or Cash Assistance, TANF (Family Independence), Food Stamps, SSI or Other Federal Cash Benefits, Alimony, Child Support, Social Security, Unemployment, Disability Income, Worker·s Compensation, Veteran·s Pension and Other (Specify)), then enter the Gross Amount, How Often Received? and Who Received? Money?
Tell us who lives in your home
Tell who lives in your home: list your name on the first line, then for each person enter Last Name, First Name, Middle Initial, Gender, Birthdate, Age and how the person is related to you.
Tell us where you work or attend school or training
Tell where you work or attend school or training: enter the Name of Parent/Guardian/Foster Parent under Parent A, Work/School/Training Information, and under Parent B (Spouse or Child's Other Parent, if in same household), Work/School/Training Information.
Check all that apply under Employment/School/Training Status: Employed, Attending School/Training, Disabled, Employed and Attending School/Training, Protective Services, Federal Declared Emergency; then enter the Employer or the School/Training Program Attending.
Enter the Employer Address or School/Training Address (Including city, state, zip), the Contact Person at Work or School/Training with the Contact Person's Phone No., and how many hours you work or attend school/training each week.
Tell us about the children who need child care services
Tell about the children who need child care services; if you need to enter additional children, make another copy of the page that lists the children before completion.
For each child enter the Child's First Name, Last Name, Social Security Number, Birthdate and Age, and check Yes or No for Race, Status (Is the child a citizen? If no, are they a legal alien?) and Additional Information, with Does the child currently attend school?
Enter the School District and check Yes or No for Health and for Attends half day only?
Check Yes or No for Attends full day? and Child care needed all year?
Check Yes or No for Ethnicity (Hispanic/Latino), for immunizations up to date?, for Child care needed school year only? and for Child care needed for school breaks and summer breaks only?
Checking No under immunizations up-to-date does not automatically disqualify your child.
Applicant Rights and Responsibilities: signature
Please print your name; by your signature you certify that all of the information you have provided is true and correct.
Signature of Parent/Caretaker.
Enter the Name of Provider Selected and the Address of Provider Selected.
Sign and date this Application.
More rules for DSS Form 3791
Complete the form in blue or black ink.
The ABC Child Care Program will not pay for any children who are served prior to receiving written authorization by the ABC Program.
If you are not sure what to send, or need assistance in completing this application, please call 1-800-476-0199.
Common questions about DSS Form 3791
Is there a penalty?
Deliberate misrepresentation may subject you to prosecution under applicable State and Federal criminal statutes.
Sources
[1] DSS Form 3791 (SEP 11), Child Care Application, South Carolina Department of Social Services (the Official source link on this page).