C-‐WAGES FCC FAMILY INCOME VERIFICATION FORM Dear Parent, Your child’s provider is applying for funding under the San Francisco C-‐WAGES FCC program (Compensation, Wage Augmentation Grants and Economic Support). The purpose of this program is to help licensed family child care providers operating in the City/County of San Francisco cover the cost of providing quality care, and to increase wages of their teaching staff based on education and job responsibilities. In order to be eligible to participate, providers must demonstrate that they are serving a significant number of families at a certain income level, according to the state income guidelines. If your family income falls below the threshold below, please sign and return the form directly to your provider. When considering your family income, please consider the following: • Include monthly gross income of all family members living in your household. • Do not include SSI/SSP income. • If your child is a foster child or you receive TANF for your child as a non-‐needy payee, only include the Foster care payment or the TANF payment. Do not report other family income. Family Size à 1-‐2 persons 3 persons 4 persons 5 persons 6 persons 7 persons 8 persons Monthly Incomeà $3,613 $4,463 $5,314 $6,164 $7,014 $7,173 $7,333 The data will only be used to evaluate your child care provider’s eligibility for funding and will be held in the strictest confidence. Thank you for supporting your provider’s eligibility for funding. Your provider may also participate in other City funded programs such as Preschool for All, or be eligible to apply for a Quality Improvement Grant through the Low Income Investment Fund. These programs also require Parent Income Verification forms. In order to reduce the number of times a parent is asked to fill out these forms, with a parent’s consent, the programs may release the income verification included in this document to another City funded program for which your provider is applying. Do you give consent to release the income information on this form to other City funded programs? ¨ Yes ¨ No Based upon the information above, I do hereby certify that my family would qualify as low-‐income under the government guidelines above. ____________________________________ ___________________________ __________________ Parent’s Name Parent’s Signature Date _________________________________________ _________________________ _____________ Home Address City Zip Code ____________________________________ ______________ _________________ _____________ Child’s Name Date of Birth Date of Enrollment Hours per week ____________________________________ Name and Signature of Child Care Provider