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srvase llamar al 1-888-214- 5437.

Application Form
Care 4 Kids 1344 Silas Deane Hwy Rocky Hill, CT 06067-1339

) Deaf and hearing-impaired individuals may use TTD/TTY line 1-877-455-9169 (

Care 4 Kids operates the child care assistance program for the State of Connecticut. The purpose of this form is
to collect information we need to determine if you are eligible to receive assistance from the Care 4 Kids program.
To apply for child care benefits, follow these easy steps:

Complete this application form. If you have any questions or need help, call 1-888-214-5437.

Complete the parent provider agreement form (PPA), with your child care provider. If your
provider is new to the Care 4 Kids program, your provider also needs to fill out the enclosed W-9
form and return it with the completed PPA. Each provider must complete a separate PPA so, if
you have more than one provider or need another PPA, call 1-888-214-5437.

to see what verifications are

Provide all needed Verification. Follow the CHECKLIST
required. If you send copies of the requested verifications with your application, we can process
your application faster. Do not send original verifications. Care 4 Kids will not return original
documents. If you do not have all the verifications, you may still send in your application but you
must send the required information as soon as possible.

Send your completed application, parent provider agreement (PPA) and verifications to the
Care 4 Kids address at the top of this page. Be sure to put enough postage on your envelope. If
you have chosen a child care provider, include the completed PPA. Please make sure your
application and PPA are signed and dated.

Note: You may submit the completed application, even if you have not yet selected a child care
provider. If you need help finding a licensed child care provider, call 2-1-1 Child Care at 211 or 1800-505-1000.

Certain information that you have given on this form must be verified before Care 4 Kids can grant
assistance. The following list will give you an idea of the documents that may be used to prove your
statements.
Income from Employment You may use copies of the most recent pay stubs or a statement from your
employer on company letterhead.
Self-Employment You may use tax records, your last tax return or receipts of business income and
expenditures.
Social Security Income Current award notice, copy of current check or statement from social security
Work Schedule Time card or statement from employer on company letterhead verifying your schedule
Child Support Paid Copy of a cancelled check, money order or wage stub showing deduction
Foster Care Payment Copy of your foster care stipend check or award letter from Department of Children
and Families
Rental Income Copy of leases, business records or income tax records

CHECKLIST  Do not forget to send in verifications requested

THE CARE 4 KIDS GOAL IS TO PROCESS YOUR APPLICATION WITHIN 30 DAYS

Care 4 Kids Application (rev. 06/06) Page 1 of 6

Section 1: Applicant Information (Tell us who you are)

The applicant is the parent or adult responsible for the child(ren). If the parent of the child in need of care is under the age
of 18 and living with another adult, then that adult is considered the applicant and must complete and sign this application.
Have you ever applied for cash, medical or food stamp assistance from the Department of Social Services? (Answering
this question will not affect your eligibility.)
If yes, what is your DSS client identification number? __________________________
First Name

Middle Initial

Last Name

Date of Birth
Apt

Address
State

City

Zip

Home phone

Work phone

___ Is this application for child care assistance for a Foster Child? Yes

Social Security Number (optional)

Sex:

Female Male

Marital Status:

Race:

(circle all that apply)

AA - American Indian/Alaskan Native

Asian

Black

NP - Native Hawaiian/Pacific Islander

- White

Unknown

Hispanic: Yes

No

No

Married Single Separated

Marque aqu si desea recibir cartas y formularios en espaol.

(Check here if you want to receive letters and forms in Spanish.)

Section 2: Children Information (Tell us about all the children living in your home)
TABLE A: CHILDREN WHO NEED CHILD CARE

In this section, please list only those children who need child care assistance from this program.

To be eligible, most children must be under age 13. Children with special needs may be eligible up to age 19. Special
needs may include a physical or mental impairment, a severe behavioral disturbance or developmental delay. Special
needs must be confirmed by a health care professional and the child must need extra supervision, care or assistance
in the child care setting.

All children in Care 4 Kids must be up-to-date on their shots (immunizations).

By law we need to ask your child's race. Identify your child's race by circling all the races that apply in the column
Race of Child in Table A.

KEY AA - American Indian/Alaskan Native A- Asian B - Black NP - Native Hawaiian/Pacific Islander W- White U - Unknown
First name,
Middle initial,
Last name

Date
of birth

Relationship
of child
to Applicant

Sex

Is this child
Hispanic?

Social
Security
Number
(optional)

Is this
child a
US
citizen?

Does this
child have
special
needs?

Race
of child

Is this child
up to date
with shots?

1.

M
F

YES
NO

YES
NO

YES
NO

AA
A
B

NP
W
U

YES
NO

2.

M
F

YES
NO

YES
NO

YES
NO

AA
A
B

NP
W
U

YES
NO

3.

M
F

YES
NO

YES
NO

YES
NO

AA
A
B

NP
W
U

YES
NO

4.

M
F

YES
NO

YES
NO

YES
NO

AA
A
B

NP
W
U

YES
NO

5.

M
F

YES
NO

YES
NO

YES
NO

AA
A
B

NP
W
U

YES
NO

Care 4 Kids Application (rev. 06/06) Page 2 of 6

TABLE B: CHILDREN UNDER 18 IN HOME WHO DO NOT NEED CHILD CARE

Please list any other children under 18 living in your home who do not need child care.
First name, middle initial, last name

Date of birth

Sex

1.

2.

Relationship
of child to Applicant

Social Security Number (optional)

M
F
M
F

Do any of the children listed above have their own children living in your home? Yes No
If YES, please list the names of the under 18 parent(s) and the name(s) of their children:
Under 18 Parent(s):

_________________________________ Child/ren: ___________________________________

_________________________________

___________________________________

_________________________________

___________________________________

_________________________________

___________________________________

_________________________________

___________________________________

Section 3: Adult Information (Tell us about all other adults living in your home)

TABLE C: ADULTS IN THE HOME OTHER THAN THE APPLICANT

Please list all other adults over 18, excluding yourself, living in your home. Include your spouse and any relatives and
non-relatives who live in your home.

If more space is needed, please write the information on another piece of paper and attach it to the application.

First name, middle initial,

last name

Date
of birth

Sex

Relationship
to Applicant

Social
Security Number
(optional)

Is this person
unable to
provide child
care because
of a disability?

1.

M
F

YES
NO

2.

M
F

YES
NO

Section 4: Child Support Paid (Tell us about Child Support you pay)

Is this person a
parent of child
living in the home?

YES NO
Name of child
_______________

YES NO
Name of child
_______________

If you or another adult living in your home pays child support for a child who does not live with you, that amount may be
used to reduce your income when determining income eligibility for assistance.
Do any adults in your home pay child support for a child who does not live with you? YES NO
If YES, payment is made to ___________________________ payment is made by_____________________________
What is/(are) the name(s) of the child(ren) being paid for?__________________________________________________
How much is paid? $___________________ per __________

date payments started_________________________

(time period)

 Please send us verification that an adult in your home pays child support.
Care 4 Kids Application (rev. 06/06) Page 3 of 6

Section 5: Work/Education/Training Activities

Please list all parents and other adults, including your self, who are working, in training or in school. Include parents or
other persons responsible for the children in the home and their spouses.

Be sure to include work, training or school information. Fill out information and schedule for each activity (i.e., working,
in training, in school) a parent/adult participates in.

1. Name of Parent or Other Adult: __________________________________________________________________

Type of Activity:

Work

Education

High School

Other(describe)

Self-Employed

Training

Do you work at home?

Yes

No

Phone

Name of Employer/Program/School
Address

City ____________________ State _______ Zip __________

Start Date of Work/Program/School _________

Name of Employment Services Case Manager, if any

PARENT/ADULT SCHEDULE BY DAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

AM

AM

AM

AM

AM

AM

AM

PM

PM

PM

PM

PM

PM

PM

AM

AM

AM

AM

AM

AM

AM

PM

PM

PM

PM

PM

PM

PM

Start time*

End time*
* - Fill in the time you are required to start the activity and the time the activity ends including meal and break times.

If workdays or hours of work vary, please explain: _____________________________________________________

How long does it take you to get to this activity from the child care setting? _______
How long does it take you to get from this activity to the child care setting? _______
Do you take public transportation to or from this activity?

Yes

No. If yes,

What is the bus route number? __________________

2. Name of Parent or Other Adult: ___________________________________________________________________

Type of Activity:

Work

Education

High School

Other(describe)

Self-Employed

Training

Do you work at home?

Yes

No

Phone

Name of Employer/Program/School
City

Address

State

Zip

Start Date of Work/Program/School: _________ Name of Employment Services Case Manager, if any:

PARENT/ADULT SCHEDULE BY DAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

AM

AM

AM

AM

AM

AM

AM

PM

PM

PM

PM

PM

PM

PM

AM

AM

AM

AM

AM

AM

AM

PM

PM

PM

PM

PM

PM

PM

Start time*

End time*
* - Fill in the time you are required to start the activity and the time the activity ends including meal and break times.

If work days or hours of work vary, please explain: _____________________________________________________

How long does it take you to get to this activity from the child care setting? _______
How long does it take you to get from this activity to the child care setting? _______
Do you take public transportation to or from this activity?

Yes

No

If yes, What is the bus route number __________________

Care 4 Kids Application (rev. 06/06) Page 4 of 6

Section 6: Income Information (Tell us about your family income)

 Please send us verification of all income your family receives. (See page 1, for a list of documents you can
use to verify your familys income)

Please list all the income your family receives including:

Gross earnings before taxes or deductions for all parents and adult family members in your home

Unearned income before deductions for all adults & children in your home (such as SSI, Social Security, etc.)
Persons with
Income

Wages

Name
__________________

Name
__________________

Name
__________________

Name
__________________

$ _______________

$ _______________

$ _______________

$ _______________

* per wk bwk sm
(circle one)

* per wk bwk sm
(circle one)

* per wk bwk sm
(circle one)

* per wk bwk sm
(circle one)

mo

mo

mo

mo

Selfemployment

$ _______________

$ _______________

$ _______________

$ _______________

per week or month

(circle one)

per week or month

(circle one)

per week or month

(circle one)

per week or month

(circle one)

SSI

$ _______________

$ _______________

$ _______________

$ _______________

per month

per month

per month

per month

$ _______________

$ _______________

$ _______________

$ _______________

per month

per month

per month

per month

$ _______________

$ _______________

$ _______________

$ _______________

per month

per month

per month

per month

Unemployment
Compensation

$ _______________

$ _______________

$ _______________

$ _______________

per month

per month

per month

per month

DCF Stipend

$ _______________

$ _______________

$ _______________

$ _______________

per month

per month

per month

per month

Other Income

$ _______________

$ _______________

$ _______________

$ _______________

Type:_______________

Type:_______________

Type:_______________

Type:_______________

* per wk bwk sm
(circle one)

* per wk bwk sm
(circle one)

* per wk bwk sm
(circle one)

* per wk bwk sm
(circle one)

Social
Security
Rental Income

(e.g.Alimony,
pensions, workers
compensation,
veterans benefits
dividends /interest
( if over$600/year)

mo

mo

mo

mo

* per: weekly (wk), bi-weekly (bwk), semi-monthly (sm), monthly (mo)

 Please send copies of your MOST RECENT paycheck stub(s) with this application. Processing of
your application will be delayed if the most recent pay stubs are not submitted.

If you are paid once a week, send copies of the last four paycheck stubs.
If you are paid every other week or twice a month, send copies of the last two paycheck stubs.
If you are paid once a month, send a copy of the last paycheck stub.
If you are self-employed, send a copy of your most recent state or U.S. tax return, including the schedules or your most
recent quarterly state or U.S. tax filing.

Do you receive Food Stamps?

YES

Do you receive housing assistance?

NO (Answering this question will not affect your child care benefit.)

YES

NO (Answering this question will not affect your child care benefit.)

Do you receive child care assistance from another source?

YES

NO

If YES, from whom: __________________________ How much? $____________ How often? ____________
Care 4 Kids Application (rev. 06/06) Page 5 of 6

Section 7: Parent's Rights & Responsibilities

Please read the following section carefully or have it read to you. If there is anything you do not understand, you
may call Care 4 Kids at 1-888-214-KIDS (5437) and ask that it be explained to you.
When you have read the section or had it read to you, please sign in the space provided at the bottom of this
page.
You have certain rights and there are certain rules you need to follow.
You have the right to file an application, withdraw an application or discontinue your participation in Care 4 Kids
at any time. You have the right to choose any eligible child care provider.
You have the right to be treated fairly by Care 4 Kids without regard to race, color, religion, sex or sexual
orientation, marital status, national origin, ancestry, age, political beliefs or disability. You have the right to
request forms and notices in Spanish. All non-English speaking participants have the right to the services of an
interpreter.
You have the right to ask for a review of any decision made by Care 4 Kids on your application/enrollment. You
have the right to speak to a supervisor or mediator and the right to request a hearing from the Department of
Social Services (DSS).

I understand and agree that:

I must report any changes in my situation to Care 4 Kids within 10 days of the change, including but not limited to
changes in address, income, household size, child care provider, hours of employment or training, additional
hours of care, etc.

Care 4 Kids may verify the information I have given on this form. I understand that if I am eligible for Care 4
Kids, benefits will not begin any earlier than 15 days before the date the application is received.

The information on this form is confidential. DSS or its agent will only use this information to administer a DSS
program. Information may be shared with others as permitted by law.

Care 4 Kids employees may provide my child care provider with information about my eligibility for Care 4 Kids
and the amount of the Care 4 Kids payment.

On request, Care 4 Kids may be required to provide information on program applicants and participants to law
enforcement officials.

The child care arrangement is between my provider and me. DSS and Care 4 Kids are not responsible for the
child care arrangement.

The Department of Social Services may conduct an unscheduled home visit.

Care 4 Kids may not pay the full amount charged by my provider. I am responsible for paying all additional
provider charges.

Providers must meet state health, safety and licensing requirements to be eligible for payment.

I may be required to repay any benefits received in error, including administrative errors. I may be subject to
criminal prosecution for fraud if I knowingly supply any false information to Care 4 Kids or fail to report changes
on time. I also may be disqualified from the program. In order to remain eligible, I must cooperate with the Care 4
Kids and DSS quality control process.

Applicants please read and sign: I have read my rights and responsibilities or have had them read to me in
a language I understand. I certify under penalty of perjury that all the information provided is true and correct
to the best of my knowledge.
Applicant Signature ___________________________________________ Date

_________________

Did another person help you fill out this form? YES NO
If yes, printed name: ____________________________

Signature: _______________________________

CHECKLIST  Do not forget to send in all verifications requested

Mail this application to: Care 4 Kids 1344 Silas Deane Hwy Rocky Hill, CT 06067-1339
The Connecticut Department of Social Services sponsors the Care 4 Kids program.
All Department of Social Services programs are administered in a non-discriminatory manner,
consistent with equal employment opportunities and affirmative action requirements.

Care 4 Kids Application (rev. 06/06) Page 6 of 6