1. finance
2. grants, scholarships and financial aid
3. financial aid

NEW YORK CITY ADMINISTRATION FOR CHILDREN’S SERVICES
DIVISION OF CHILD CARE AND HEAD START
Photo: Paul S. Stetzer
ELIGIBILITY DETERMINATION &
ENROLLMENT MANUAL
Version 1.0
August 2012
EarlyLearn Eligibility Determination & Enrollment Manual
1
TABLE OF CONTENTS
Introduction and Eligibility Guidelines
3
Eligibility Categories & Criteria
5
Child Care Eligibility
7
Documents Required for Child Care Subsidy Applications
9
Social and Financial Eligibility Considerations
11
Social Eligibility Criteria and Required Documents
13
Financial Eligibility Criteria and Required Documents
18
Fee Determination
21
Conversion to Monthly Income
22
Exclusions from Monthly Gross Income
23
Priority Codes
24
Head Start Eligibility
25
Enrollment
30
Application for Child Care Subsidy (CS 925)
Attachment A
Instructions for Completing CS 925 (CS 925A)
Attachment B
Fee Schedule
Attachment C
Head Start Income Guidelines
Attachment D
Head Start Statement of Non-Verifiable Income
Attachment E
Head Start Sample Residency Question
Attachment F
Head Start Eligibility Verification Form
Attachment G
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INTRODUCTION
Welcome to EarlyLearn NYC. You are now an integral part of New York City’s
Administration for Children’s Services (ACS) mission to provide an integrated, highquality early care and education system that:
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Raises program standards and expected child outcomes, ensuring programs are
developmentally focused
Encompasses important support services for all children and families
Increases coordination of service delivery among systems and government
agencies
Economically integrates early care settings that both low-income and middleincome families access
In order to meet the goals set forth in EarlyLearn NYC, it is important for each program
to understand their program model type as well as the various eligibility regulations
associated with each model. This guide was created to assist you by providing an
overview of these concepts and step by step instructions on how to determine a family’s
eligibility for subsidized child care services and successful enrollment of children into
your program. This guide also includes information on the recertification process.
EARLYLEARN NYC - ELIGIBILITY GUIDELINES
The information provided in this guide reflects the eligibility guidelines for non
Temporary Assistance for Needy Families (TANF) families. Parents or caretakers
receiving TANF, also known as Cash Assistance (CA), that are engaged in an approved
work activity must be referred to their respective Human Resources Administration
(HRA) Job Center (Cash Assistance office) where their eligibility will be determined.
Note - Families in receipt of SSI do not need to have their eligibility approved at an HRA
Job Center in order to be enrolled in a Head Start program.

All applicants must live in one of the five boroughs of New York City, unless the
child(ren) resides in a certified foster home outside of NYC.
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Each EarlyLearn NYC contractor/program is responsible for determining eligibility.
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Parental choice and responsibility to choose and monitor care for their children
must be respected. Parents should receive information from EarlyLearn programs
on: types of care available, regulatory standards, how to choose a provider, and how
to file a complaint if they feel that a provider is violating the laws and regulations
governing child care. In accordance with the New York City Health Code, all
EarlyLearn NYC programs shall provide parents with the NYC Department of Health
and Mental Hygiene brochure on how to get information on early care and education in
New York City.
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Preventive, Protective, and Employed Foster Care families must use licensed care.
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Any family eligible for EarlyLearn NYC shall not be denied and/or discriminated
against the use of the service on the basis of race, sex, religion, or any other factor
prohibited by law.
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The period of eligibility for EarlyLearn NYC services varies depending on the program
model type and the family’s reason for care.

Certification of child care eligibility remains at ACS’ Division of Child Care and Head
Start (CCHS) according to New York State Regulations. This function is a
responsibility of ACS/CCHS Resource Areas and HRA Job Centers. Certification of
Head Start eligibility remains the responsibility of the local Head Start program.

Parents should be informed that all disclosed information related to eligibility is
subject to verification.
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Programs are expected to maintain confidentiality of all information received and
keep materials secured at all times.
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ELIGIBILITY CATEGORIES AND CRITERIA
Children must meet subsidized Child Care or Head Start criteria, and in some instances,
meet both the Child Care and Head Start eligibility criteria (dually-eligible) in order to be
enrolled in an EarlyLearn NYC program. The model types and the eligibility criteria for
each model are provided below.
Child Care:
In order to be eligible for Child Care services a child shall be between the ages of 6
weeks – 13 years of age (18 years if the child has a documented special need). The Child
Care Development Block Grant has an income limit of 200% of the State Income
Standard (SIS). However, if additional City funding is available, Children’s Services
allows families to exceed the State maximums, as follows:
 275% SIS for a family of 2
 255% SIS for a family of 3
 225% SIS for a family of 4 or greater
The family must also document a reason for care. The reasons for care include:
 Employment
 Training/Education
 Child Welfare (Protective, Preventive, Employed Foster Care)
 Receipt of Domestic Violence Services
Head Start:
In order to be eligible for Head Start services a child shall be either 3 or 4 years of age
and shall meet one or more of the following criteria:
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Family income below 100% of Federal Poverty Level (FPL)
Receiving cash assistance through TANF
Homeless (as defined by the McKinney Vento Act)
Child is a foster child
After priority is given to those meeting the above criteria, programs with Head Start
funding may serve a limited number of families with incomes between 100% and 130%
of FPL (up to a maximum of 35%), and an additional 10% with incomes above 130% of
FPL.
Within these broad eligibility requirements, contractors are expected to develop
selection criteria, based on the needs of the community, to determine which families’
applications will receive preference for enrollment.
Note: Federal Poverty Level and State Income Standard are equivalent.
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Dual Child Care/Head Start:
In order to be eligible for a dual slot, a child must meet the Head Start age and income
requirements.
 Child must be pre-school age (3 years or 4 years)
 Family income below 100% of FPL (A child may also qualify for dual eligibility
through use of a Head Start “over-income” slot, if income eligible for child care.)
 Recipient of cash assistance through TANF
The family must also document a reason for care. The reasons for care include:
 Employment
 Vocational Training, Education, or Rehabilitation
 Homeless/Domestic Violence
 Preventive/Protective Services
 Employed Foster Care
Universal Pre-Kindergarten (UPK):
Each EarlyLearn contractor has a specific target number for UPK enrollment that is
based on a percentage of their pre-school children. The percentage is the same for all
contractors and depends on the overall allocation of ACS UPK slots from NYC’s
Department of Education (DOE). Funding is integrated into the EarlyLearn NYC contract.
A child is eligible for UPK if he or she resides in New York City, and will be 4 years old by
December 31st of the school year.
Redirection of Non-Head Start/Child Care Eligible Families:
ACS programs prioritize families eligible for Head Start and/or Child Care in their UPK
program enrollment. While non-Head Start/Child Care eligible families can join UPK
waitlists at ACS programs, ACS programs must first meet their contractual obligation
before enrolling non Head Start/Child Care eligible children in their UPK program. ACS
programs are required to provide non-Head Start/Child Care eligible families the contact
information to find other community-based organizations and public school UPK
options. For more information about public school UPK options, families should call the
DOE Office of Student Enrollment (718-935-2009).
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CHILD CARE ELIGIBILITY
Child Care subsidized services are funded by several Federal, State and local resources.
Each funding stream has eligibility requirements for the differing types (modalities) of
care. ACS, as the local social service district for New York City, is the recipient of the
New York City allocation of the federal Child Care Development Block Grant, and
governs the eligibility requirements for subsidized child care.
Age Eligibility
 Eligible children are between the ages of 6 weeks – 13 years of age (18 years if
the child has a documented special need). Contracted center-based care is for
children between the ages of 6 weeks and up to 5 years of age (kindergarten
eligible). Contracted Family Child Care is for children between the ages of six (6)
weeks and up to four (4) years of age (UPK eligibility).
For purposes of determining eligibility a “Child Care Services Unit” (or Family) is defined
as any/all adults (21 years of age or older) and children residing in the same household.
Application Form for Child Care Subsidy
CS 925 The Application for Child Care Subsidy (see Attachment A) is the basic
form to be completed and submitted to the ACS/CCHS Resource Area together
with the required documents for financial and/or social eligibility. This
application is to be used for families that are dually eligible (Head Start and Child
Care) and those that will occupy child care only slots.
CS 925A Instructions for Completing the Application Form (See Attachment B)
provides detailed guidelines on how to accurately complete the form.
The Applicant may fill out and submit the completed form to the child care
program for review of entries and to check the completeness of required
documents to substantiate financial and/or social eligibility.
Note: The CS 925 is for low-income families. Cash Assistance families should be referred
to their assigned HRA Job Center for eligibility determination. Protective, Preventive,
and employed Foster Care families must utilize a CS 186-D referral process.
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Who completes the CS 925 Application Form?
The CS 925 is completed by the applicant or an authorized representative.
The applicant is the person applying for child care services. He/she may be a:

Parent - natural or adoptive parent.

Foster Parent - adult substitutes or replacements for natural
parents, in accordance to specific standards of the Department of
Social Services.

Caretaker Relative - the non-legally responsible blood relative of
the child; limited to adult siblings, grandparents, great
grandparents, aunts, uncles, great uncles, great aunts, or first
cousins with whom the child lives.

Non-legal Guardian - non-legally responsible adults who have
children in their care. No financial or social eligibility is
determined for these individuals. Care is provided based on the
needs of the child.
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DOCUMENTS REQUIRED FOR CHILD CARE SUBSIDY APPLICATIONS
I.
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II.
REQUIRED DOCUMENTS TO BE SUBMITTED BY ALL APPLICANTS
Proof of Birth for every child in the home under age 18 (birth certificate,
baptismal record, alien registration card)
Proof of Address (ex. current utility bill, lease, etc.)
Public Assistance/Medicaid Card (if applicable)
Proof of child’s Alien Registration Status, if not born in the U.S. (alien registration
card, INS form I-94, etc.) – must be original documents
Social Security Cards for parent(s) and children (optional)
REQUIRED DOCUMENTS FOR FINANCIAL AND SOCIAL ELIGIBILITY
1. Employment
Pay Stubs
 Bi-weekly or Semi-Monthly - last two (2) current and consecutive pay
stubs (if pay does not fluctuate); last six (6) current and consecutive pay
stubs (if pay fluctuates)
 Weekly – last 4 current and consecutive pay stubs (if pay does not
fluctuate); last 12 current and consecutive pay stubs (if pay fluctuates)
CS 1069 Form - Referral to Employer for Income Information (accepted only
when pay stubs are unavailable or insufficient)

.
Self-Employed – Form 1040 and appropriate Schedules - should be
referred to the Resource Area for eligibility determination and
processing
2. School/Vocational Training
 CS 1082 - Vocational Training Verification
Note: A letter from the training institution on official letterhead is also
acceptable.
3. Homeless/Domestic Violence
 If the family is homeless, documentation of the family’s temporary
address (shelter, living with another family, in a hotel/motel, or in a car,
park, bus, train or campsite) should be provided.
 Documentation from the agency providing domestic violence services to
the family is required and should include days and hours attended.
Note: If the applicant is a caretaker, they must complete the Caretaker Relative
Statement in addition to the above required documents.
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4. Preventive/Protective Services / Foster Care
 CS 186D-2 Referral for Child Care and Head Start Services
Note: More detailed information about required documents can be found in the
Child Care Subsidy Application Instructions (CS 925A).
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SOCIAL AND FINANCIAL ELIGIBILITY CONSIDERATIONS
Eligibility for subsidized child care is based on social and financial considerations.
Families requesting child care services must establish that:
1. All families must have a documented “reason for care” (social eligibility).
and
2. Families receiving subsidy because they are low income and are working, in an
approved educational/vocational activity or need child care to attend domestic
violence services, must fall within the Federal/State income limitations on either
a “no cost” or “fee paying” basis (financial eligibility).
In determining financial eligibility for child care, the applicant is considered under any
one of the following statuses:
1. Income Support Status
Income Support Status describes families (adults and/or children) in receipt of cash
assistance from the Temporary Assistance to Needy Families (TANF) or the Safety
Net programs. These services are also referred to as public assistance (PA),
Temporary Assistance (TA), or income maintenance.
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If a parent, caretaker, or child is in receipt of PA/TANF, they are automatically
eligible for a child care subsidy.
No fees are assigned to families receiving TANF / Cash Assistance / Safety Net /
or PA.
2. Income Eligible Status
Income Eligible Status describes families who are not in receipt of benefits from a
TANF / Safety Net/ PA program, and the family’s income is equal to or less than
the maximum income eligibility level.
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A family’s gross income and family size will be used to determine whether it is
financially eligible for child care subsidies.
Fees for child care are based on a fee schedule that utilizes a sliding fee scale.
Foster care families and caretaker families are assigned a minimum fee (refer to
latest fee schedule – Attachment C).
Fees are attached to the youngest child receiving child care unless the youngest
child is a Head Start child. In families where there is more than one child
receiving care, fees are paid to the provider caring for the youngest child.
Families in receipt of Child Protective Services are not required to pay a fee.
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When employment is an applicant’s reason for care, they must document
income equal to or greater than the minimum wage ($7.25/hr).
The following applicants are exempt from earning minimum wage:
 Applicants on public assistance
 Self employed and has potential for growth in earnings to produce such
income within a reasonable period of time.
 Companion for the elderly
 Worker with disabilities
 Federal criminal investigator
 Fishermen
 Newspaper deliverer
 Newspaper employee of limited circulation newspapers
 Seaman on other-than-American vessels
 Switchboard operator
3. Status Without Regard to Income
Individuals and families who are socially eligible for Protective and Preventive
Services are determined eligible without regard to financial eligibility criteria.
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SOCIAL ELIGIBILITY CRITERIA AND REQUIRED DOCUMENTS
REASONS FOR CARE
The following are the acceptable “reasons for care.”
1. Employment
2. Vocational Training, Education, or Rehabilitation
3. Homeless/Domestic Violence
4. Preventive/Protective Services
5. Employed Foster Care
Note: If the child is in a two-parent household, both parents must have an acceptable
reason for care.
1. EMPLOYMENT
Eligibility Criteria
Applicant must be employed for a minimum of 20 hours per week. Applicant
must be earning at least the minimum wage. The authorized days/hours of child
care must be reasonably related to the applicant’s work schedule.

Hours of work vary from week to week
If an applicant’s number of hours worked varies from week to week, the
employee must average 20 hours per week over a 12 week period.

New applicant starting work
For persons starting new employment, the application may be taken 30 days
prior to the start date and child care may be authorized to begin two (2)
weeks prior to the employment start date.
Period of Eligibility
Dual Programs:
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/Head Start program, the length of eligibility is equal to the two (2)
year Head Start eligibility period, regardless of the documented reason for
care.
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/UPK program, the length of eligibility is until the subsequent
school year, regardless of the documented reason for care
 If the child is infant or toddler age, the maximum period of eligibility is one
(1) year.
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Child Care Only Programs
 The maximum length of eligibility is one (1) year
 For temporary work assignments, shortened eligibility is applied and ends
when the work assignment ends
 Shortened eligibility is also applied for three (3) months when the applicant
has new employment that has not yet begun
Required Documentation
[ ] Pay Stubs
Bi-weekly or Semi-Monthly - last two (2) current and
consecutive pay stubs (if pay does not fluctuate); last six
(6) current and consecutive pay stubs (if pay fluctuates)
Weekly – last four (4) current and consecutive pay stubs (if
pay does not fluctuate); last 12 current and consecutive
pay stubs (if pay fluctuates)
[
] CS 1069
Referral to employer for employee income information in
instances where pay stubs are either unavailable or are
insufficient
Note: The CS 1069 is also used to verify the start date for future employment
that has not yet started.
2. VOCATIONAL TRAINING, EDUCATION, OR REHABILITATION
Eligibility Criteria
 Applicant must be enrolled full-time (12 semester hours), in an approved
vocational training program, two-year College or educational program.
 Training program must have a specific vocational objective; Adult Basic
Education (ABE), English as a Second Language (ESL), or a General
Equivalency Diploma (GED).
 Vocational and two-year college programs must be approved or licensed by
the NYS Board of Higher Education, the NYC Department of Education, or the
NYC Department of Employment. If a client receives a government grant or
stipend such as PELL, TAP, etc. it can be assumed that the school/program is
approved.
 Enrollment in more than two consecutive Vocational Training Institutions
(non-degree), when in care, does not meet eligibility criteria.
 The authorized days/hours of care must be reasonably related to the training
activity.
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Additional Vocational Training Info
 Applicants Starting Training
Child care may be authorized to begin two (2) weeks prior to the training
start date.

Two-Year College
Two-year college students may be authorized for a period not to exceed 30
calendar months. This period begins on the day the child(ren) enter service
and ends when the applicant has had 30 months of child care. Remediation
courses such as pre-college work, GED, and English as a Second Language
(ESL) are not counted towards the 30 month limit.
Period of Eligibility
 Child care services may be authorized for the duration of the program, but
not to exceed one (1) year.
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/Head Start program, the length of eligibility is equal to the two (2)
year Head Start eligibility period, regardless of the documented reason for
care.
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/UPK program, the length of eligibility is until the subsequent
school year, regardless of the documented reason for care.
Required Documentation
[ ] ACD 1082
Vocational Training Verification
Note: A letter from the training institution on official letterhead is also
acceptable. The letter must include the length of the program, projected date of
completion, vocational objective or course of study, the number of credits or an
official detailed class schedule, as well as documentation of grants, stipends, or
scholarships received by the student.
3. HOMELESS / DOMESTIC VIOLENCE
Eligibility Criteria
Homeless – Families are defined as homeless if they reside at a temporary
address including a shelter, live with another family, in a hotel/motel, or in a
car, park, bus, train or campsite (see page 26 for full description).

For child care eligibility, the applicant must also be employed, as described in
the employment section.
Domestic Violence – An applicant is eligible when a parent is referred for child
care services, from a social service or preventive agency, to participate in
services for domestic violence.
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Period of Eligibility
 For homeless families, child care services may be authorized for up to one (1)
year, unless a shorter period is specified.
 For domestic violence, child care services may be authorized for up to (1)
year, unless a shorter period is specified.
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/Head Start program, the length of eligibility is equal to the two (2)
year Head Start eligibility period, regardless of the documented reason for
care.
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/UPK program, the length of eligibility is until the subsequent
school year, regardless of the documented reason for care.
Required Documentation
[ ] Referral form from Social Service Agency servicing the family.
4. PREVENTIVE/PROTECTIVE SERVICES
Eligibility Criteria
 Children referred for protective or preventive services by ACS and/or a
contracted preventive services agency are eligible for care.
 In a multi-child family, if one child is authorized for Preventive/Protective
reasons, all children in the household may receive care.
 No fee is assigned to protective cases. However, income information should
be recorded for informational purposes only.
 Child care must be provided in a licensed facility.
Period of Eligibility
 Child care services may be authorized for up to six (6) months, unless a
shorter period is specified.
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/Head Start program, the length of eligibility is equal to the two (2)
year Head Start eligibility period, regardless of the documented reason for
care.
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/UPK program, the length of eligibility is until the subsequent
school year, regardless of the documented reason for care.
Required Documentation
[ ] CS 186D-2
Referral for Child Care and Head Start Services
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5. EMPLOYED FOSTER CARE
Eligibility Criteria
Foster children, directly referred by a voluntary foster care agency, stating that
child care is needed because the foster parent is employed are eligible for care.
ACS approval is needed for employed foster parents.
Period of Eligibility
 Child care services may be authorized for up to one (1) year, unless a shorter
period is specified.
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/Head Start program, the length of eligibility is equal to the two (2)
year Head Start eligibility period, regardless of the documented reason for
care
 If at least one child in the family is pre-school age and enrolling in a Dual
Child Care/UPK program, the length of eligibility is until the subsequent
school year, regardless of the documented reason for care.
Required Documentation
[ ] CS 186D-2
Referral for Child Care and Head Start Services
Note: A current pay stub (or Employer Letter) is required as proof of
employment.
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FINANCIAL ELIGIBILTY CRITERIA AND REQUIRED DOCUMENTS
Financial eligibility for subsidized child care is based on gross income and family size.
Refer to the latest fee schedule at the end of this section. The fee schedule is revised
annually based on changes in the State Income Standard or Federal Poverty Level.
INCOME ELIGIBLE STATUS
1. EMPLOYMENT INCOME
Eligibility Criteria
 Applicant(s) must be employed for a minimum of 20 hours per week.
Required Documentation
[
] If the gross pay does not vary, current and consecutive pay stubs for the
last four (4) weeks
[
] If the gross pay varies, current and consecutive pay stubs for the last 12
weeks
Or
[
] CS 1069 - Referral to employer for employee semi-monthly income
information in instances where pay stubs are either unavailable or are
insufficient
Note: Pay stubs are the preferred documentation and are required for
employees who receive them. The CS 1069 is only acceptable for new
employment, for employees who are paid in cash, or when pay stubs do not
include identifying information (i.e. name, number of hours worked, etc.) or are
lost or stolen.
Reminder: Be sure to ask clients if they have any additional employers.
2. ALIMONY / CHILD SUPPORT
Required Documentation
[ ] Self-attestation of any Alimony/Child Support received is required on CS 925
or CS 1068.
Note: The applicant/client should provide a copy of the court order or other legal
documentation when available.
3. UNEMPLOYMENT / WORKER’S COMPENSATION
Required Documentation
[ ] Current Benefits Rate Letter from New York State Unemployment Benefits
indicating amount of weekly benefits to be issued.
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For Unemployment:
i. If the client has applied for unemployment and the amount of income
is not known, the client must provide a letter from the New York
State Department of Labor - Division of Employment Services Office
indicating that the client has applied for unemployment
compensation. A notarized letter from the client explaining how they
are supporting themselves is also required.
ii. If the client is being supported by someone else, that individual must
provide a notarized letter detailing the amount and/or kind of
support being provided.
For Worker’s Compensation:
i. Copy of Worker’s Compensation check
ii. Copy of current Worker’s Compensation report
iii. Award Letter
4. SELF-EMPLOYMENT INCOME
Required Documentation
[
] Copy of the complete income tax return (1040) including the appropriate
schedules

For a new business, operating three (3) months or less, a notarized
statement including:
i. date business began
ii. gross Income
iii. itemized deductions
iv. net income
v. total hours worked per week
vi. name and type of business
vii. address of business

For a new business, operating for more than three (3) months, an
accountant’s statement on the accountant’s letterhead including:
i. date business began
ii. gross income
iii. itemized deductions
iv. net income
5. SOCIAL SECURITY, SSI, DISABILITY, RETIREMENT, PENSION / ANNUITY INCOME
Required Documentation
[ ] Copy of most recent check or pay stub
[
] Benefit Award Letter or official bank statement showing Direct Deposit
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6. OTHER INCOME (DIVIDENDS, INTEREST INCOME FROM ESTATES OR TRUSTS,
ROYALTIES, TIPS, COMMISSIONS, ETC.)
Required Documentation
 Dividends – a statement of earnings for the last quarter from the brokerage
house, mutual fund, or company in which the stock is owned.

Interest – a bank book with the interest entered within the last three
months. Interest for a certificate of deposit of longer duration is included for
the eligibility period in which the maturation occurs.

Income from Estates or Trust – a statement within the last three (3) months
from the executor of the estate or trust containing the amount and
frequency of income and the name of the beneficiaries.

Royalties – IRS Form Schedule E and/or a contract stating the percentage and
frequency of income as well as a statement of earnings for the last three (3)
months from the contractor.

Tips/Commissions – Records of the amount of tips and commissions for the
month:
1. The same documentation as listed under Monthly Wages or Salary Before
Deductions with specific details listed for tips and commissions (see CS
1069 or pay stubs)
2. IRS 1040 – from the previous year
3. When tips and commissions cannot be verified/documented in any of the
above, calculate 15% of the gross income and enter that amount
Employees who receive tips must earn at least $7.25/hr through a combination
of tips and a minimum cash wage paid by the employer. The minimum cash
wage employers must pay is:
 Food Service Workers - $5.00/hr
 Service Employees in Resort Hotels - $4.90/hr
 Service Employees in all other establishments - $5.65/hr
Note: Tips + Salary = $7.25/hour
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FEE DETERMINATION
STATUS WITHOUT REGARD TO INCOME
1. Caretaker / Non-Legal Guardian / One Person Family – Pay minimum fee
a. Only the child’s income is considered towards financial eligibility.
b. If the child’s income exceeds the state maximum per person, the child is
ineligible for subsidized care
2. Foster Care
Foster care cases are charged minimum fees for subsidized child care services. The
foster parent’s employment must be verified.
3. Protective Service Cases
Protective cases are not charged fees for subsidized child care services. Protective
services cases do not have to meet the financial eligibility criteria requirements.
However, income information must be recorded and verified for informational
purposes.
4. Income Support/TANF (Cash Assistance Families)
There is no fee for these families.
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CONVERSION TO MONTHLY INCOME
To determine financial eligibility, all income must be converted to monthly amounts in
the following manner. Note: Calculated fees should be rounded to the nearest whole
dollar amount.
FREQUENCY
DESCRIPTION
CONVERSION METHOD/EXAMPLE
Weekly
paid once per week
Multiply by 4.33
Ex.: $150 weekly income
$150 x 4.33 = $649.50/month
Bi-Weekly
paid every two (2) weeks
Divide by 2 and multiply by 4.33
Ex.: $500 bi-weekly income
$500 / 2 = $250
$250 x 4.33 = $1082.50/month
Semi-Monthly
paid two (2) times per
month
Multiply by 2
Ex.: $300 Semi-monthly income
$300 x 2 = $600/month
Daily
paid each day worked
Total for week and multiply by 4.33
Ex.: 3 days work at $30, $22, and $25
$30 + $22 + $25 = $77
$77 x 4.33 = $333.41/month
Monthly
paid once per month
No conversion needed
Quarterly
paid every three (3)
months
Divide by 3
Ex.: $2400 quarterly income
$2400 divided by 3 = $800/month
Annually
paid once per year
Seasonally
paid for work done on a
seasonal basis
Divide by 12
Ex.: $10,000 annual income
$10,000 divided by 12 =
$833.33/month
Annual total divided by 12
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EXCLUSIONS FROM MONTHLY GROSS INCOME
Income Exempt List
The following types of income are excluded from the computation of monthly gross income:
1.
Per capita payments to, or funds held in trust for, any individual in satisfaction of a judgment of
the Indian Claims Commission or the Courts of Claims;
2.
Money received from sale of property, such as stocks, bonds, a home, or a car (unless the person
was engaged in the business of selling such property, in which case the net proceeds would be
counted as income from self-employment);
3.
Withdrawals of bank deposits;
4.
Money borrowed;
5.
Tax refunds;
6.
Gifts;
7.
Lump sum inheritances or insurance payments;
8.
Capital gains;
9.
The value of coupon allotments under the Food Stamp Act of 1964, as amended, in excess of the
amount paid for coupons;
10.
The value of USDA donated foods;
11.
The value of supplemental food assistance under the Child Nutrition Act of 1966 and the special
food service program for children under the National School Lunch Act;
12.
Any payment received under the Uniform Relocation Assistance and Real Property Acquisition
Policies Act of 1970;
13.
Earnings of a child under 14 years of age (no inquiry shall be made);
14.
Loans and grants, such as scholarships obtained and used under conditions that preclude their use
for current living expenses;
15.
Any grant or loan to any undergraduate student for educational purposes made or insured under
Higher Education Act;
16.
Home produce utilized for household consumption;
17.
Payments made for child care services, or the value of child care services provided to a recipient of
child care services provided under the New York State Child Care Block Grant program and under
Title XX of the Social Security Act who is applying for or receiving any other services funded under
any federal or federally assisted program that bases eligibility for such services upon need or the
amount of benefits upon need;
18.
Payments to foster parents.
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PRIORITY CODES
When filling vacancies in your Child Care program, the following list of priorities should
be the guide for placement and enrollment. In situations where competing families fall
within the same priority category for service, the date of the certified application will
determine which family will fill the vacancy.
Priority 1
Protective Cases – Referrals from ACS for protective reasons.
Priority 2
Preventive Cases – Referrals from ACS or Preventive Services Agencies for
preventive reasons. Foster Care cases are also included in this category.
Priority 3
Cash Assistance and Transitional Child Care
Employment – Cash Assistance (CA) recipients who are employed in an
approved work activity or receiving transitional benefits.
Training – PA recipients who are in approved training/education program.
Transitional Benefits – A working client whose CA case was closed because of
employment.
Priority 4
Homeless – Families who are homeless. For child care eligibility, the family
must also be employed.
Domestic Violence – Families receiving services due to domestic violence.
Special Needs – Child(ren) has a documented special need. Family must also
have a documented reason for care (such as Employment).
Priority 5
Employment – Employed parent/caretaker/relative.
Priority 6
Training/Education – Parent/caretaker attending an approved
vocational/training program.
Note:


If there are two parents in the household, both parents must have an
acceptable reason for care (except for protective/preventive cases).
If there are two reasons for care, the lower priority (which is the higher
number) applies. Example: If the mother works (priority 5) and the
father is in training (priority 6), the case is considered priority 6.
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HEAD START ELIGIBILITY
Federal policies with respect to Eligibility, Recruitment, Selection, Enrollment and
Attendance in Head Start (ERSEA) may be found in Part 1305 of the Head Start
Performance Standards. Additionally, revised regulations may be found in Sections 640
and 645 of the Head Start Act of 2007.
Age Eligibility
 Children who will be three (3) by December 31st may enroll in Head Start in
September of that year, provided your license permits enrollment of children
younger than three (3).
 Children who turn 3 after January 1st may not enroll until their third birthday. All
four year olds may enroll, but can be counted as UPK children only if they are
four (4) by December 31st of the year for which they are enrolled in UPK.
 Children who turn five (5) during the school year may stay in your program until
they are eligible for kindergarten.
Documents for proof of identity/age (any one): Birth certificate; Baptismal or other
religious certificate; official hospital or other documented birth record; adoption record;
or passport.
Income Eligibility/Categorical Eligibility
Age-eligible children are automatically (categorically) eligible for Head Start if:
 Their family is homeless, as defined in Section 725(2) of the McKinney-Vento
Homeless Assistance Act (42 U.S.C.11434a(2)).
 They are in foster care.
 The family is receiving public assistance (TANF or SSI).
Children/families not falling into one of these three categories are eligible for Head Start
if their family income falls below 100% of the Federal Poverty Level (FPL). See
Attachment D for a copy of the Head Start Income Guidelines.
Family: For purposes of determining eligibility, a family is defined as all persons living in
the same household who are:
1. Supported by the income of the parent(s) or guardian(s) of the child enrolling or
participating in the program, and
2. related to the parent(s) or guardian(s) by blood, marriage, or adoption
Income: Income means gross cash income and includes earned income, military income,
veterans benefits, Social Security benefits, unemployment compensation and public
assistance benefits.
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25
Required Income Documentation (any one for each earner):
[ ] Pay stubs or pay envelopes
[
] Letter from employer, on company letterhead, signed and dated
[
] Income Tax Form 1040
[
] W-2
[
] Unemployment benefits award letter or correspondence from NYS Department of
Labor
[
] Documentation for TANF or SSI recipients
[
] Child Support or Alimony check stubs or letter from person providing support or
from court.
Note: Section 645(a)(30(A) of the Head Start Act of 2007 requires that certain types of
pay and allowances to members of the uniformed services not be counted as income for
purposes of determining eligibility. Specifically, the following two pay/allowances are to
be excluded:
 The amount of any special pay payable under section 310 of title 37, USC,
relating to duty subject to hostile fire or imminent danger.
 The amount of basic allowance payable under section 403 of title 37, including
any housing allowance.
If an applicant is claiming no income the program is responsible for discussing the
situation with the family in order to understand their situation, and what sources of
support are available to them to meet their on-going needs. The program needs to
gather sufficient relevant evidence to make as informed a judgment as possible about
the family’s eligibility status. If the program then determines they accept the family’s
assertion that it has no income it can apply the selection criteria for determining
whether to enroll the child. (See Attachment E)
One example of a family with no income is a mother with a three year old, both of
whom live with the mother’s parents. Since it is only the income of the child’s parents
or guardians that is used for determining family income this family would indeed have
no income.
Note: The period of time to be considered for eligibility is the 12 months immediately
preceding the month in which the application for enrollment of a child in a Head Start
program is made, or for the calendar year immediately preceding the calendar year in
which the application is made, whichever more accurately reflects the family’s current
needs.
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Programs should include a residency question as part of the intake process. By asking
this question of everyone, homeless families can be identified without undo stigma.
Based on the response, it can be determined whether the family meets the criteria for
categorical eligibility. Clarifying information may be elicited through conversation during
the intake process or collected subsequently from a third party with first hand
knowledge of the of the applicant’s eligibility, with the explicit written consent of the
applicant. A sample residency questionnaire is included (see Attachment F).
A “homeless child,” as defined in the McKinney-Vento Homeless Assistance Act, is one
who lacks a “fixed, regular, and adequate nighttime residence.” The definition goes on
to specify examples, such as:
 Children who are sharing housing of other persons due to loss of housing,
economic hardship, or similar reasons; are living in motels, hotels due to lack of
alternative accommodations; are living in emergency or transitional shelters; or
are awaiting foster care placement;
 Children who have a primary nighttime residence that is a public or private place
not designed for or ordinarily used as a regular sleeping accommodation for
human beings;
 Children who are living in cars, parks, public spaces, abandoned buildings,
substandard housing, bus or train stations or similar settings.
In determining whether a child is living in “substandard” housing, Head Start staff must
evaluate whether the child’s housing situation falls short of community standards or is
of lower quality than the law prescribes. Staff should consider factors such as health
and safety concerns, the number and age of occupants and the number of occupants
per square foot.
Residence: While Head Start does not require proof of residence, the program should
assure itself, using such procedures as it deems appropriate, that the child lives within
the program’s service area. Since DOE requires proof of residence for children enrolled
in UPK, the Head Start agency should obtain this documentation at initial enrollment.
Acceptable proof of residence includes: ID card with address; Postmarked envelope
with name and date; Drivers license; Utility Bill, Rent receipt or lease with name and
home address; Correspondence from a government agency which contains name and
street address.
Over-Income: In addition to families that are categorically eligible, or who meet the
income threshold, a limited number of slots may be filled by “over-income” families. As
a general rule, up to 10% of funded slots may be filled by families with incomes that
exceed 100% of FPL. There is no upper limit on allowable income for these families, as
long as the family meets the criteria that the Head Start program has established for
selecting such children.
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Under certain limited circumstances (see HS Act Section 645 (B)(iii)(II)) programs may
enroll up to 35% of their total enrollment families with incomes between 100% and
130% of FPL. To do so, the program must:
 Establish and implement outreach and enrollment policies and procedures that
ensure they are meeting the needs of categorically or income eligible children
prior to meeting the needs of children between 100% and 130% of FPL; and
 In prioritizing the selection of children to be served, the Head Start program
gives priority to categorically or income eligible children prior to serving children
between 100% and 130% of FPL.
Note: Programs that serve children under this provision of the Head Start Act have
additional mandated federal reporting requirements.
Programs are required to include in every enrolled child’s folder, a statement signed by
a Head Start employee indicating what documentation was used to determine income
eligibility, and stating that the child is income eligible (or that the child is being enrolled
as an “over-income” child). Under proposed changes to existing federal rules (published
in 2011 but not yet formally adopted) the staff person should certify that the
information on eligibility in the file is accurate to the best of the person’s knowledge,
and, based on that information, the staff person has determined the child to be eligible
for services. Additionally, programs should include copies of the actual documentation
used to make the determination, including “rationale documents” or staff notes that
served as the basis for an informed judgment where documentation is lacking.
There is no standard application form for Head Start comparable to the CS-925.
However, it is the responsibility of the program to have each applicant complete an
application form.
Applicants must sign a statement attesting to the accuracy of the information and/or
documents they submit for determining eligibility (also as per the revised federal rule).
This signature can be on the application itself or as a separate form, at the program’s
discretion, and should also be kept on file. (See attachment G)
Period of Eligibility
If a child has been found income eligible (including categorically eligible) and is
participating in a Head Start program, he or she remains income eligible through that
enrollment year and the immediately succeeding year.
Note: Re-verification of eligibility (comparable to recertification in child care) is not
required.
Selection Process
Each Head Start program must have a formal process for establishing selection criteria
and for selecting children and families for enrollment. This plan must consider all
eligible applicants for Head Start services. In selecting the children and families to be
served, the Head Start program must consider the income of eligible families, the age of
the child, and the extent to which a child or family meets the criteria that each program
is required to establish. (see Head Start Performance Standard 1305.3( c)(6))
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Selection Criteria
Each program establishes rules to determine which eligible families will receive priority
for enrollment and are based on family and/or community situations. Criteria must be
objective so as to eliminate individual or personal judgments of staff members.
Programs should use findings from their self-assessment, community assessment and
Program Information Report in determining which criteria to implement, and how to
rank them. Each factor is assigned a point value or weight, based on the emphasis given
to that criterion.
Examples of criteria include, but are not limited to:
 Child’s age (e.g. priority might be given to four (4) year olds so that they receive
at least one (1) year of pre-school before kindergarten, and help program meet
UPK targets)
 Child’s biological risks, such as a child with sickle cell anemia or a sibling with
documented disabilities
 Child with an identified or suspected disability
 Environmental risks, such as parental substance abuse or mental health issues,
or documented or suspected child abuse or neglect
 Family income (e.g. higher priority might be given to families with income below
75% of FPL)
 Family type/size, such as single parent, teen parent, or grandparent(s) headed
household
 Family needs, including literacy skills, adult education, social support
Criteria must be approved by your Policy Council/Committee before they can be
implemented. If you are a new program, which does not have an established Policy
Committee, an ad hoc committee of local parents and community members may serve
this function.
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ENROLLMENT
Maintain Full Enrollment
Each EarlyLearn NYC program is required to reach and maintain maximum enrollment
by ensuring that each available seat is filled by an eligible child. Contractors should take
all necessary actions to ensure their programs are fully enrolled. This includes
developing and utilizing a marketing plan with regular community outreach events and
information. Programs must also maintain a current and viable waiting list.
Center-Based Setting Enrollment Information
An infant or toddler is enrolled when he/she is certified eligible by ACS and begins
attending the contractor’s program site.
A pre-schooler funded by Head Start (Head Start or Dually Eligible) is enrolled when
officially accepted by a program and all procedures required to begin receiving services
are completed.
A pre-schooler funded by Child Care (not Head Start) is enrolled when he or she is
certified eligible by ACS and begins attending the contractor’s program site.
Home-Based Family Child Care Setting Enrollment
Infants, toddlers, and pre-schoolers are enrolled when they are certified eligible by ACS
and begin attending the provider home.
Universal Pre-Kindergarten (UPK) Enrollment
A child is enrolled when all required documentation has been received, approved, and
entered in the NYC DOE’s Basic Educational Data System by the State’s deadline,
typically in October.
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ENROLLMENT – Child Care Only Programs
Center-based
Programs may only enroll children that have been certified eligible for a child care
subsidy. The child may be on the program’s reservation or waiting list. Programs can
also enroll children who are determined eligible and are either on the citywide voucher
waiting list or on the reservation/waiting list of another contract program. Programs
may not enroll children who are enrolled with another program/provider. This is
important because eligible parents sometimes elect to enroll in a program with
immediate vacancies. If the family has already been determined eligible, then the
program can enroll the child.
Center-based programs will enroll children via the Web Enrollment System (WES). The
WES manual provides detailed instructions on the mechanics of enrolling children.
Programs will:






Arrange start date with parent/caretaker
Review reservation list to ensure fairness and equity (outstanding reservations
should be reconciled – children on reservation should be enrolled or the
reservations should be cancelled)
Review program waiting list to ensure compliance with priorities for child care
(programs should not routinely skip higher priority children when selecting
children for enrollment; however situations such as age of child needed to fill a
vacancy may be justifiable reasons for skipping children
Select a child from the waiting list. If the parent/caretaker refuses the
placement or the program can’t get in touch with the family, then the program
should cancel the waiting list placement in WES
After ensuring appropriate child selection, the Program should:
o Select child in WES
o Enter start date in WES
Obtain parent fee information from either the parent’s Placement Notice or,
after the enrollment is completed in WES, via the Attendance module
Note: The program will also be responsible for unenrolling children who have
dropped out of service or are no longer eligible.
Family Child Care – Family Child Care Network information is not available in WES at this
time. Programs will enroll children and drop children via a manual process, as follows:
 FCC Networks will receive a monthly 1098 Report; the report lists all children
enrolled, on reservation list, and on waiting list
 FCC Network will select the child from the reservation or waiting list and enter
the enrollment start date and Provider ID number
 FCC network forwards the 1098 report to the respective Borough Resource Area
 The Resource Area makes the enrollment via ACCIS
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


The program should obtain parent fee information from either the parent’s
Placement Notice or, after the enrollment is completed the fee will appear on
the manual ACS-1 attendance form
The FCC Network will enter drop dates for children no longer enrolled
The 1098 Report also separates children who have been deemed ineligible; the
FCC Network is responsible for unenrolling these children
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ENROLLMENT – Head Start Only Programs
Once Head Start eligibility is established and selection criteria applied, programs may
enroll children.
Children must be enrolled in a specific class, and programs must assure that class size
regulations are met.
Class size is limited as follows:
 The physical space must provide for at least 35 sq. ft. per child, and
 If the majority of children enrolled are three (3) years old, the maximum
enrollment is 17.
 If the majority of children enrolled are four (4) years old, the maximum
enrollment is 20.
Class size is established based on the age composition at the start of the school year.
For example, if the majority of children are three (3) years of age in September, then the
maximum class size of 17 applies throughout the year, even after a majority of children
have turned four (4). On an on-going basis throughout the year, programs have up to 30
days to fill a vacancy, giving preference to the family on the waiting list with the highest
ranking based on the selection criteria.
Not less than 10% of the total number of children enrolled by each agency will be
children with disabilities who are determined to be eligible for special education and
related services (Head Start Act Section 640 (7)(C)(d)(1)).
Programs will enroll children via WES. The WES manual provides detailed instruction on
the mechanics of enrolling children.
Programs will:
 Arrange start date with parent/caretaker
 Review reservation list to ensure fairness and equity (outstanding reservations
should be reconciled – children on reservation should be enrolled or the
reservations should be cancelled)
 Review program waiting list to ensure compliance with selection criteria
priorities
 If a program selects a child from the waiting list and the parent/caretaker refuses
the placement or the program can’t get in touch with the family, then the
program should cancel the waiting list placement in WES
 After ensuring appropriate child selection, the program should:
o Select child in WES
o Enter start date in WES
 The program will also be responsible for unenrolling children who have dropped
out of service
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ENROLLMENT – TANF/CASH ASSISTANCE (CA) RECIPIENTS
Parents or caretakers receiving Temporary Assistance for Needy Families (TANF), also
known as Cash Assistance (CA), and engaged in an approved work activity must be
referred to their respective HRA Job Center (Cash Assistance office) where their
eligibility will be determined. Once eligibility has been established, the Child Care
Provider Enrollment Supplement form (CS 274W) is completed by the parent/caretaker
AND the program for ALL program types. While completing the form, a start date must
be arranged with the parent/caretaker and provided on the form by the program in the
Date Care Began section of the form. The parent/caretaker then returns the completed
CS-274W to a Child Care Specialist at their respective HRA Job Center. The Child Care
Specialist will make a reservation for the child reflecting the agreed upon start date.
The program can enroll children in reservation status via the Web Enrollment System
(WES).
Notes:
 Families in receipt of SSI do not need to have their eligibility approved at an HRA
Job Center in order to be enrolled in a Head Start program.
 There are no fees for TANF/CA families.
Center-based - Programs may only enroll children that have been certified eligible for a
child care subsidy. The child may be on the program’s reservation or waiting list.
Programs can also enroll children who are determined eligible and are either on the
citywide voucher waiting list or on the reservation/waiting list of another contract
program. Programs may not enroll children who are enrolled with another
program/provider. This is important because eligible parents sometimes elect to enroll
in a program with immediate vacancies. If the family has already been determined
eligible, then the Program can enroll the child.
Center-based programs will enroll children via WES. The WES manual provides detailed
instruction on the mechanics of enrolling children.
Programs will:
 Arrange start date with parent/caretaker (upon completion of CS-274W)
 Review reservation list to ensure fairness and equity (outstanding reservations
should be reconciled – children on reservation should be enrolled or the
reservations should be cancelled)
 Review program waiting list to ensure compliance with priorities for child care
(programs should not routinely skip higher priority children when selecting
children for enrollment; however situations such as age of child needed to fill a
vacancy may be justifiable reasons for skipping children on the waitlist
 If a program selects a child from the waiting list and the parent/caretaker refuses
the placement or the program can’t get in touch with the family, then the
program should cancel the waiting list placement in WES
 After ensuring appropriate child selection, the Program should:
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34

o Select child in WES
o Enter start date in WES
The program will also be responsible for unenrolling children who have dropped
out of service
Family Child Care – Family Child Care Network information is not available in WES at this
time. The Child Care Specialists at the HRA Job Center will directly enroll children via the
Automated Child Care Information System (ACCIS). The program will be responsible for
dropping the children via a manual process, as follows:
 FCC Networks will receive a monthly 1098 Report; the report lists all children
enrolled, on reservation list, and on waiting list
 Dropping of TANF/CA children can be done at the HRA Job Center by a Child Care
Specialist or the FCC Network can enter drop dates for children no longer
enrolled on the 1098 Report
 The 1098 Report also separates children who have been deemed ineligible; the
FCC Network is responsible for unenrolling these children
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ATTACHMENT A
Application for Child Care Subsidy
(CS 925)
CS-925 (FACE)
REV. 5/07
PLEASE PRINT IN ALL CAPITAL LETTERS
Section 1
APPLICANT
OFFICE USE ONLY
APPLICATION FOR CHILD CARE SUBSIDY
Case #:
NEW
RECERTIFICATION
TRANSITIONAL CHILD CARE
nyc
ACS
NYC Administration for
Children’s Services
Application Date: ______ /______ /______
LAST Name (Please include any aliases or maiden names in parentheses):
FIRST Name:
ADDRESS Residence:
APT. #:
CITY/BOROUGH:
STATE:
ZIP CODE:
ADDRESS Mailing (if different than above):
APT. #:
CITY/BOROUGH:
STATE:
ZIP CODE:
M.I.:
TELEPHONE (Work):
TELEPHONE (Home):
TELEPHONE (Cell or Other):
(
) ____________________________________________
(
) ____________________________________________
(
) ____________________________________________
Do you receive PA? YES NO
Do you receive Medicaid? YES NO
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
FAMILY MEMBERS
LAST Name
(PLEASE INCLUDE ANY ALIASES OR
MAIDEN NAMES IN PARENTHESES)
FIRST Name
1.
2.
3.
4.
5.
6.
M.I.
RELATIONSHIP
DOES THIS
PERSON NEED
CHILD CARE?
BOTH OF CHILD’S
PARENTS RESIDE
IN THE HOME?
YES/NO
YES/NO
DATE OF
BIRTH
MM/DD/YY
SEX
M/F
YES/NO
APPLICANTʼS EMPLOYER Name:
Section 3
EMPLOYMENT
RACE
(SEE
LEGEND
BELOW)
SOCIAL
SECURITY
NUMBER
(OPTIONAL)
SELF
RACE: 1.Native American or Alaskan Native 2. Asian 3. African American/ Black 4. Native Hawaiian/Pacific Islander
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.
ADDRESS:
Hours per week:
CITY/BOROUGH:
Does Job have a Rotation Shift?
YES NO
Does Job Require O/T?
YES NO
Hours per week:
Tel #:
(
) ______________________________
STATE:
ZIP CODE:
SPOUSE/OTHER PARENT Scheduled Days and Hours of Employment(i.e.: Mon – Fri, 9 a.m. – 5 p.m.):
Are you requesting child care primarily so that you can work?
YES NO
If not, please read the instruction section titled “Child/Family Needs” and write your
reason for care here:
Tel #:
(
) ______________________________
ZIP CODE:
STATE:
SPOUSE/OTHER PARENT EMPLOYER Name:
ADDRESS:
5. Caucasian/ White
OFFICE USE ONLY
Family Size: ______
CITY/BOROUGH:
APPLICANTʼS Scheduled Days and Hours of Employment(i.e.: Mon – Fri, 9 a.m. – 5 p.m.):
Section 4
CHILD/
FAMILY
NEEDS
HISPANIC
OR
LATINO
Does Job have a Rotation Shift?
Does Job Require O/T?
YES NO
YES NO
Is the child for whom you are requesting care living with
someone other than his/her mother or father?
Does your child have any conditions that require special help or
attention?
___________________________________________________________________________ Does your child have health insurance?
YES NO
YES NO
YES NO
OVER
nyc
ACS
CS-925 (REVERSE)
REV. 5/07
Please complete income information for yourself AND anyone applying with you. See instructions for documentation requirements.
NYC Administration for
Children’s Services
Section 8
CERTIFICATION
Section 7 Section 6
CITIZEN PROVIDER
-SHIP
Section 5
OTHER INCOME EARNINGS
(This includes children in need of care, their parents, step-parent and any other children under the age of 18 in household.)
GROSS
INCOME
ITEM
OFFICE USE MONTHLY
CALCULATIONS
APPLICANT: Job earnings before deductions.
weekly bi-weekly semi-monthly other
$
SPOUSE/OTHER PARENT: Job earnings before deductions.
weekly bi-weekly semi-monthly other
FOR OFFICE USE ONLY
For all other income/ benefits please itemize below. Include the amount
INCOME
for yourself AND your spouse AND child(ren) who live with you.
DOCUMENTATION
CALCULATIONS
Alimony and/or child support. (Received)
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
BENEFITS: Social Security, SSI, Disability, Retirement and/or Pensions & Annuities.
weekly bi-weekly semi-monthly other
OTHER INCOME/BENEFITS (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).
TOTAL INCOME:
$
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: _____________________________
Address: ___________________________
PROGRAM #
Name: _____________________________
Address: ___________________________
PROGRAM #
Name: _____________________________
Address: ___________________________
PROGRAM #
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)?
YES NO
If Yes, 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.
1. I understand that the information contained on this form will be used to determine my or
York State Law and Federal Law provides that any applicant may be investigated for
my family’s eligibility for services/subsidy and that the information will only be used for
fine or jail or both, for a person found guilty of obtaining child care assistance/subsidy
the purposes of determining child care eligibility.
by concealing information or providing false information.
2. The social security numbers (if provided) will not be released as they are confidential under 4. I understand that this application is used only for the expressed purpose of child care
federal law and can be released/used only for the purposes specified in federal law.
subsidy. To obtain other assistance such as Food Stamps, Medicaid, Temporary
Assistance, or other services, additional applications will be required.
3. 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 5. I certify under the penalty of law that all the information I have supplied on this form is
providing child care, provider fees, hours for which child care is needed, and that New
true and correct.
Please provide the signature of the parent/caretaker who is applying for child care assistance or the signature of an authorized representative.
X __________________________________________________ ______ /______ /______
X __________________________________________________ ______ /______ /______
SIGNATURE PARENT/CARETAKER/WIFE/HUSBAND
DATE
___________________________________________________________________________
PRINT NAME
Section 9
OFFICE
ONLY
PLEASE PRINT
TYPE OF
DOCUMENTATION
SIGNATURE AUTHORIZED REPRESENTATIVE
______________________________________________________________________________
PRINT NAME
Enrollment Application Completed by: __________________________ ______ ______ /______ /______
PRINT AND INITIAL
DATE
ACS – Eligibility Approved by: ________________________________ ______ ______ /______ /______
PRINT AND INITIAL
Parent Fee:
DATE
______ ______ /______ /______
INITIAL
DATE
Length of Eligibility:
from: ______ /______ /______
to: ______ /______ /______
I.S. – Verified by: _______________ ______ /______ /______
PRINT AND INITIAL
DATE
DATE
CODES: RFC: _____PR: _____FS: _____
ATTACHMENT B
Instruction for Completing CS 925
(CS 925A)
CS 925A Instructions (PAGE 1
REV.01/11
OF
4)
DIVISION OF CHILD CARE AND HEAD START
nyc
A
CS
NYC
Administration
for
Administration
Childr
en’
sSer
vicesfor
Children’s Services
INSTRUCTIONS FOR COMPLETING YOUR APPLICATION FOR CHILD CARE SUBSIDY
Dear Parent/Caretaker(s),
The following instructions are provided to assist you in completing your application. Please read the instructions
very carefully. When completing your application, please remember to print clearly in block capital letters (A, B, C)
using blue or black ink.
This Application must include supporting documentation such as proof of income, proof of address and proof
of employment. Required documentation is indicated in the shaded boxes throughout these instructions.
OFFICE BOX
Gray shaded boxes are for office use only. Please do not write anything in these sections.
SECTION 1 – APPLICANT
The applicant is the adult parent or caretaker requesting care. Unless otherwise noted, this section must contain the
following information for the applicant only:
1) Last and First Name. Please put any aliases or maiden names in parentheses.
2) Address (residence).
3) Address (mailing), if different than residential address.
4) Telephone Numbers – work, home and cellular (if applicable).
5) Public Assistance Status and Medical Status (if you are a PA recipient, you should apply for child care through your
job center worker).
6) Primary Language.
DOCUMENTATION: Include (1) of the following as proof of address: 1) Utility bill (gas, electricity or telephone),
2) Rent receipts, 3) Section 8 award letter, 4) NYCHA certificate.
SECTION 2 – FAMILY MEMBERS
Unless otherwise noted, in this section you must:
1) List the last and first names of everyone who lives with you and any aliases or maiden names in parentheses, of
everyone who lives with you.
2) Fill in your relationship with everyone living in the home (e.g.self, spouse,my child’s parent, child, adopted child,
foster child, sister, mother, etc).
3) Write “YES” or “NO” to indicate whether this family member requires child care.
4) Write “YES” or “NO” to indicate whether both of the child’s parents live in the home.
Note: If one or both parents do not live in the home, you must complete the absent parent form included in this packet.
5) Fill in the Date of Birth, Sex, Hispanic and Race columns for everyone who lives with you.
Note: You must indicate whether each household member is Hispanic or Latino and you must select Racefor each
household member. However, you may choosemultiple Racecategoriesfor a single person.
6) Fill in the social security number for your family members. You may but do not have to list Social Security Numbers.
Social Security Numbers may be used by federal, state and local agencies to prevent duplication of services, fraud and
for federal reporting.
7) Attach a separate sheet for additional household members (if there are more than six).
DOCUMENTATION: Include (1) of the following to verify the identity of all children under 18: 1) Copy of a birth
certificate, 2) Baptismal record, 3) Passport, 4) Alien registration card with your signature on the copy.
CS 925A Instructions (PAGE 2
REV.01/11
OF
4)
nyc
ACS
N YC Administration
AdministrationServices
for
Children’s
SECTION 3 – EMPLOYMENT
Children’s Services
In this section, include employment information only for parents or step-parent of the children for whom you are applying for
a subsidy, if they live in the home.
Applicant/Spouse/Other Parent:
1) Employer’s name, address and telephone number.
2) Hours worked per week.
3) List scheduled days and hours of employment (i.e. Monday – Friday, 9am – 5pm).
4) Check if your job has a rotating shift and/or requires overtime.
SECTION 4 – CHILD/FAMILY NEEDS
1) Check “YES” or “NO” to indicate whether your reason for requesting a child care subsidy is so that you can work.
2) If the reason you are applying for a child care subsidy is NOT so that you can work, please choose the appropriate
reason from this list and write it on the blank line in the application:
a) Vocational Training, Educational Activities, or Rehabilitation (excluding four year college).
b) Seeking Employment.
c) Illness or Incapacity.
d) Necessary Absence from the Home.
e) Social Service Referral for Family or Child.
Note: Preventive and Protective Service – Families requesting child care for protective/preventive services are eligible
for child care without regard to income and do not need to complete this application. Families meeting this
requirement are determined eligible for child care as part of their application for protective/preventive services.
3) Check “Yes” or “No” to indicate if there is a non-custodial parent available to provide child care.
4) Check “YES” or “NO” to indicate whether the child for whom you are applying lives with someone other than his/her
mother or father (e.g. foster parents, grandparents, etc.).
5) Check “YES” or “NO” to indicate whether the child for whom you are applying has special needs.
Note: If your child has special needs you may document his/her need for additional attention by including
an Individualized Educational Plan (IEP) or a pediatrician’s written statement.
6) Check “YES” or “NO” to indicate whether the child for whom you are applying has health insurance.
Note: If your child does not have insurance he/she may be eligible through Child Health Plus. For more
information, please call 311.
DOCUMENTATION (You must document any reason for care other than employment independent of income
documentation):
REASON FOR CARE (Section 4): Include (1) of the following if you are applying for child care for a reason other
than current employment:
1) Vocational Training, Educational Activities, or Rehabilitation – Vocation Training Verification: ACD-1082.
2) Seeking Employment – One of the following: a) UIB Book or b) NYSES registration card.
3) Illness or Incapacity – ACD 1039 (medical referral form) completed by a doctor, clinic, or hospital.
4) Necessary Absence from the Home – Both of the following: a) Notarized statement from applicant indicating
reason for absence from home, hours of absence, days of absence, total absence time, and b) supporting
documents (e.g. doctor’s letter).
5) Social Service Referral for Family or Child – Social Service Referral Form: ACD-1019
SPECIAL NEEDS (Section 4): Include (1) of the following to verify your child’s special needs:
1) Individualized Educational Plan (IEP).
2) Pediatrician’s written statement.
(PAGE 3
OF
4)
CS 925A Instructions (PAGE 3
REV.01/11
OF
4)
nyc
ACS
nyc
ACS
NYC Administration
for
NYC
Administration
Children’s Services
Administration
for
Children’s
Services
– EARNINGS
AND
INCOME
SECTION
5 –OTHER
EARNINGS
AND OTHER INCOME
Children’s Services
income/benefits
information
for yourself information
AND anyone
(Thisapplying
includeswith
children
in need
of
Please include
income/benefits
forapplying
yourself with
ANDyou.
anyone
you. (This
includes
children in need of
nts, stepparent
and
any
additional
children
under
age
18
in
household.)
care, their parents, stepparent and any additional children under age 18 in household.)
Applicant/Spouse/Other
Parent:
1) Earnings – Applicant/Spouse/Other
Parent:
ne box to indicate
whether
you to
are
paid weekly,
biweekly,
or other. semi-monthly, or other.
a) Check
one box
indicate
whether
you aresemi-monthly,
paid weekly, biweekly,
your gross income
per pay
income).
b) Provide
yourperiod
gross (pre-tax
income per
pay period (pre-tax income).
documentation
below
for a list of acceptable
c) (see
Include
documentation
(see belowdocumentation).
for a list of acceptable documentation).
me – Applicant
and/or
other–parent
living
in theother
home
and/or
children
living children
in the home:
2) Other
Income
Applicant
and/or
parent
living
in theunder
home18and/or
under 18 living in the home:
ceive alimonya)
and/or
support,
unemployment
worker’s
compensation,
a net
income fromhave
self- a net income from selfIf youchild
receive
alimony
and/or child and/or
support,
unemployment
and/or have
worker’s
compensation,
t and/or rental
income,
indicate
how
frequently
you
collect
that
income.
employment and/or rental income, indicate how frequently you collect that income.
frequently
you collect
income. you collect the income.
your pre-tax b)
income
from
each
source
and indicate
howsource
Provide
your
pre-tax
income
from each
and indicate
howthe
frequently
documentation
eachdocumentation
income source.for each income source.
c) for
Include
Applicant and/or
other–parent
living
in theother
home
and/or
children
living children
in the home:
3) Benefits
Applicant
and/or
parent
living
in theunder
home18and/or
under 18 living in the home:
ceive social security,
disability,
and/or
pensions
and annuities,
other
a) If youSSI,
receive
socialretirement
security, SSI,
disability,
retirement
and/or and/or
pensions
andincome/benefits,
annuities, and/or other income/benefits,
w frequently indicate
you collect
that
income.
how frequently you collect that income.
your pre-tax b)
income
from
each
source
and indicate
howsource
frequently
you collect
income. you collect the income.
Provide
your
pre-tax
income
from each
and indicate
howthe
frequently
documentation
eachdocumentation
income source.for each income source.
c) for
Include
me/Benefits
Applicant
and/or other–parent
living
in theother
home
and/or
children
living children
in the home:
4) –Other
Income/Benefits
Applicant
and/or
parent
living
in theunder
home18and/or
under 18 living in the home:
ll applicable boxes
to indicate
whether
you to
collect
specific
income/benefits.
a) Check
all applicable
boxes
indicate
whether
you collect specific income/benefits.
ot need to include
specific
amounts.
b) You documentation
do not need to or
include
documentation
or specific amounts.
NTATION:
DOCUMENTATION:
of the following
for yourself
AND
anyonefor
applying
with
youanyone
to verify
your income/benefits:
Include
all of the
following
yourself
AND
applying
with you to verify your income/benefits:
mployment Income 1)
– Employment Income –
Pay stubs (if you receive
them)
four(ifcurrent,
consecutive
weekly
pay stubs
if they are
exactly
same,
twoare exactly the same, two
a) Pay
stubs
you receive
them) four
current,
consecutive
weekly
pay the
stubs
if they
current, consecutive bi-weekly
orconsecutive
semi-monthly
pay stubs
if they are exactly
same,
or are
twelve
weekly
current,
bi-weekly
or semi-monthly
pay the
stubs
if they
exactly
the or
same, or twelve weekly or
six biweekly/semi-monthly
consecutive paycurrent,
stubs if consecutive
they are not pay
identical.
sixcurrent,
biweekly/semi-monthly
stubs if they are not identical.
ACD-1069 is requiredb)if you
are paidis in
cash orifby
check
without
a pay
ACD-1069
required
you
are paid
in cash
orstub.
by check without a pay stub.
mony/Child Support
ACD-1081 and,
if available,
court order
decree,
or separation
2)–Alimony/Child
Support
– ACD-1081
and,ofif support,
available,divorce
court order
of support,
divorce decree, or separation
pers.
papers.
employment – UIB3)book
or benefits rate
letter.
Unemployment
– UIB
book or benefits rate letter.
lf Employment – 4) Self Employment –
Business and Personal
taxand
returns
are required
you
are self
andemployed
schedules(IRS 1040 and schedules
a) income
Business
Personal
income iftax
returns
areemployed
required if(IRS
you1040
are self
C and SE for sole proprietorship,
1065, Schedules
and1065,
SE for
partnership)
C and SEand
for IRS
sole 1040,
proprietorship,
and IRS K-1
1040,
Schedules
K-1 and SE for partnership)
Notarized statement of
if self-employed
thanif three
months. less than three months.
b)income
Notarized
statement of less
income
self-employed
Accountants statement
self-employed
betweenifthree
months and
one year.
c) ifAccountants
statement
self-employed
between
three months and one year.
cial Security, Disability,
Retirement,
Pensions,
Worker’s
Compensation,
SSI – Copy
of checks, SSI – Copy of checks,
5) Social
Security,
Disability,Annuities,
Retirement,
Pensions,
Annuities, Worker’s
Compensation,
rent award letters, or current
the SSAaward
Formletters,
245B. or the SSA Form 245B.
edicaid – Photo ID, 6)
Medicaid
Card.
Medicaid
– Photo ID, Medicaid Card.
CS 925A Instructions (PAGE 4
REV.01/11
OF
4)
SECTION 6 – PROVIDER
nyc
ACS
NYC
Administration
for
Administration
Childr
en’
sSer
vicesfor
Children’s Services
1) You have the option to choose center-based care, family day care or informal care.
2) If you know where you would like to enroll your child in care, please provide the name of that provider and an alternate.
You may also want to indicte the types of care you would consider in case no slots are available with the providers you
listed.
3) If you do not know where you would like to enroll your child in care, please indicate the types of care that you are
interested in:
a) Center Based Care – Child care and education in centers that care for groups of children together in classrooms. Please
note that center based care programs operated by religious schools or in public schools on their premises do not
have to be licensed or registered.
b) Head Start – Developmentally focused pre-school for three and four year olds living in very low income families. Head
Start includes family social services and emphasizes parental involvement.
c) Family Day Care – Care by a licensed provider for a small number of children in his/her own home.
d) Informal Care – Friends, relatives or neighbors caring for one or two childern. Please note that informel care providers
do not have to be licensed or registered.
4) If you would like to list a third provider preference you may attach a separate sheet.
SECTION 7 – CITIZENSHIP LEGAL STATEMENTS
In this section, include citizenship information for the child/children for whom you are applying. The child/children must be
either a US Citizen or a legal resident. Parents’ immigration status does not impact eligibility for the Child care subsidy.
You must complete and sign this written certification of citizenship on behalf of the child/children for whom you are applying.
Note: If your child is not a United Statescitizen, eligibilit y for child care must be determined in person at a resource
area. Please contact your resourcearea to makean appointment and bring the child/children’sproof of legal
residency (immigration department form I-94, alien registration card, naturalization papers, or lawyer’s letter) to
the appointment.
LEGAL RESIDENCY FOR NON CITIZEN CHILDREN:
If your child is not a US citizen, eligibility for child care must be determined in person at a resource area. Please
contact your resource area to make an appointment and bring (1) of the following as proof of your child/children’s
legal residency:
1) Immigration department form I-94
2) Alien registration card
3) Naturalization papers
4) Lawyer’s letter
SECTION 8 – CERTIFICATION AND SIGNATURE
Please read the certification section carefully and sign. If the applicant is completing the application for someone else,
he/she must sign his/her own name.
SECTION 9 – OFFICE
Do not complete this section. This will be used by staff in determining your family’s eligibility for care.
In addition to the Application for Care Subsidy, make sure you have been given copies of:
• LDSS-4148A: “What You Should Know About Your Rights and Responsibilities”
• LDSS-4148B: “What You Should Know About Social Services Programs”
• LDSS-4148C: “What You Should Know If You Have an Emergency”
These booklets contain important information about your rights and responsibilities.
ATTACHMENT C
Fee Schedule
Administration for Children's Services
Division of Child Care
WEEKLY FEE
FULL
PART
TIME
TIME
35% rate above SIS / 17% cap
SIS as of January 2011
March 25, 2011
CHILD CARE FEE SCHEDULE Monthly Incomes
Effective May 2011
MONTHLY GROSS INCOME
FAMILY SIZE=2
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=3
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=4
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=5
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=6
FROM
TO
WEEKLY FEE
FULL
PART
TIME
TIME
$15
$15
$16
$17
$18
$19
$20
$12
$12
$12
$12
$13
$14
$15
below 1226
1,227
1,424
1,436
1,449
1,461
1,473
1,226
1,423
1,435
1,448
1,460
1,472
1,485
below 1545
1,546
1,742
1,755
1,767
1,779
1,792
1,545
1,741
1,754
1,766
1,778
1,791
1,803
below 1863
1,864
2,061
2,073
2,085
2,098
2,110
1,863
2,060
2,072
2,084
2,097
2,109
2,122
below 2181
2,182
2,379
2,391
2,404
2,416
2,428
2,181
2,378
2,390
2,403
2,415
2,427
2,440
below 2500
2,501
2,697
2,710
2,722
2,734
2,747
2,500
2,696
2,709
2,721
2,733
2,746
2,758
$15
$15
$16
$17
$18
$19
$20
$12
$12
$12
$12
$13
$14
$15
$21
$22
$23
$24
$25
$26
$27
$28
$29
$30
$15
$16
$17
$18
$18
$19
$20
$21
$21
$22
1,486
1,498
1,511
1,523
1,535
1,548
1,560
1,572
1,585
1,597
1,497
1,510
1,522
1,534
1,547
1,559
1,571
1,584
1,596
1,609
1,804
1,817
1,829
1,841
1,854
1,866
1,878
1,891
1,903
1,916
1,816
1,828
1,840
1,853
1,865
1,877
1,890
1,902
1,915
1,927
2,123
2,135
2,147
2,160
2,172
2,184
2,197
2,209
2,222
2,234
2,134
2,146
2,159
2,171
2,183
2,196
2,208
2,221
2,233
2,245
2,441
2,453
2,466
2,478
2,490
2,503
2,515
2,527
2,540
2,552
2,452
2,465
2,477
2,489
2,502
2,514
2,526
2,539
2,551
2,564
2,759
2,772
2,784
2,796
2,809
2,821
2,833
2,846
2,858
2,871
2,771
2,783
2,795
2,808
2,820
2,832
2,845
2,857
2,870
2,882
$21
$22
$23
$24
$25
$26
$27
$28
$29
$30
$15
$16
$17
$18
$18
$19
$20
$21
$21
$22
$31
$32
$33
$34
$35
$36
$37
$38
$39
$40
$23
$24
$24
$25
$26
$27
$27
$28
$29
$30
1,610
1,622
1,634
1,647
1,659
1,672
1,684
1,696
1,709
1,721
1,621
1,633
1,646
1,658
1,671
1,683
1,695
1,708
1,720
1,732
1,928
1,940
1,953
1,965
1,977
1,990
2,002
2,015
2,027
2,039
1,939
1,952
1,964
1,976
1,989
2,001
2,014
2,026
2,038
2,051
2,246
2,259
2,271
2,283
2,296
2,308
2,321
2,333
2,345
2,358
2,258
2,270
2,282
2,295
2,307
2,320
2,332
2,344
2,357
2,369
2,565
2,577
2,589
2,602
2,614
2,627
2,639
2,651
2,664
2,676
2,576
2,588
2,601
2,613
2,626
2,638
2,650
2,663
2,675
2,687
2,883
2,895
2,908
2,920
2,932
2,945
2,957
2,970
2,982
2,994
2,894
2,907
2,919
2,931
2,944
2,956
2,969
2,981
2,993
3,006
$31
$32
$33
$34
$35
$36
$37
$38
$39
$40
$23
$24
$24
$25
$26
$27
$27
$28
$29
$30
$41
$42
$43
$44
$45
$46
$47
$48
$49
$50
$30
$31
$32
$33
$33
$34
$35
$36
$36
$37
1,733
1,746
1,758
1,771
1,783
1,795
1,808
1,820
1,832
1,845
1,745
1,757
1,770
1,782
1,794
1,807
1,819
1,831
1,844
1,856
2,052
2,064
2,077
2,089
2,101
2,114
2,126
2,138
2,151
2,163
2,063
2,076
2,088
2,100
2,113
2,125
2,137
2,150
2,162
2,175
2,370
2,383
2,395
2,407
2,420
2,432
2,444
2,457
2,469
2,482
2,382
2,394
2,406
2,419
2,431
2,443
2,456
2,468
2,481
2,493
2,688
2,701
2,713
2,726
2,738
2,750
2,763
2,775
2,787
2,800
2,700
2,712
2,725
2,737
2,749
2,762
2,774
2,786
2,799
2,811
3,007
3,019
3,032
3,044
3,056
3,069
3,081
3,093
3,106
3,118
3,018
3,031
3,043
3,055
3,068
3,080
3,092
3,105
3,117
3,130
$41
$42
$43
$44
$45
$46
$47
$48
$49
$50
$30
$31
$32
$33
$33
$34
$35
$36
$36
$37
$51
$52
$53
$54
$55
$56
$57
$58
$59
$60
$38
$39
$39
$40
$41
$42
$42
$43
$44
$45
1,857
1,870
1,882
1,894
1,907
1,919
1,932
1,944
1,956
1,969
1,869
1,881
1,893
1,906
1,918
1,931
1,943
1,955
1,968
1,980
2,176
2,188
2,200
2,213
2,225
2,237
2,250
2,262
2,275
2,287
2,187
2,199
2,212
2,224
2,236
2,249
2,261
2,274
2,286
2,298
2,494
2,506
2,519
2,531
2,543
2,556
2,568
2,581
2,593
2,605
2,505
2,518
2,530
2,542
2,555
2,567
2,580
2,592
2,604
2,617
2,812
2,825
2,837
2,849
2,862
2,874
2,887
2,899
2,911
2,924
2,824
2,836
2,848
2,861
2,873
2,886
2,898
2,910
2,923
2,935
3,131
3,143
3,155
3,168
3,180
3,192
3,205
3,217
3,230
3,242
3,142
3,154
3,167
3,179
3,191
3,204
3,216
3,229
3,241
3,253
$51
$52
$53
$54
$55
$56
$57
$58
$59
$60
$38
$39
$39
$40
$41
$42
$42
$43
$44
$45
Page 1
Administration for Children's Services
Division of Child Care
WEEKLY FEE
FULL
PART
TIME
TIME
35% rate above SIS / 17% cap
SIS as of January 2011
March 25, 2011
CHILD CARE FEE SCHEDULE Monthly Incomes
Effective May 2011
MONTHLY GROSS INCOME
FAMILY SIZE=2
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=3
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=4
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=5
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=6
FROM
TO
WEEKLY FEE
FULL
PART
TIME
TIME
$61
$62
$63
$64
$65
$66
$67
$68
$69
$70
$45
$46
$47
$48
$48
$49
$50
$51
$51
$52
1,981
1,993
2,006
2,018
2,031
2,043
2,055
2,068
2,080
2,092
1,992
2,005
2,017
2,030
2,042
2,054
2,067
2,079
2,091
2,104
2,299
2,312
2,324
2,337
2,349
2,361
2,374
2,386
2,398
2,411
2,311
2,323
2,336
2,348
2,360
2,373
2,385
2,397
2,410
2,422
2,618
2,630
2,643
2,655
2,667
2,680
2,692
2,704
2,717
2,729
2,629
2,642
2,654
2,666
2,679
2,691
2,703
2,716
2,728
2,741
2,936
2,948
2,961
2,973
2,986
2,998
3,010
3,023
3,035
3,047
2,947
2,960
2,972
2,985
2,997
3,009
3,022
3,034
3,046
3,059
3,254
3,267
3,279
3,292
3,304
3,316
3,329
3,341
3,353
3,366
3,266
3,278
3,291
3,303
3,315
3,328
3,340
3,352
3,365
3,377
$61
$62
$63
$64
$65
$66
$67
$68
$69
$70
$45
$46
$47
$48
$48
$49
$50
$51
$51
$52
$71
$72
$73
$74
$75
$76
$77
$78
$79
$80
$53
$54
$54
$55
$56
$57
$57
$58
$59
$60
2,105
2,117
2,130
2,142
2,154
2,167
2,179
2,192
2,204
2,216
2,116
2,129
2,141
2,153
2,166
2,178
2,191
2,203
2,215
2,228
2,423
2,436
2,448
2,460
2,473
2,485
2,497
2,510
2,522
2,535
2,435
2,447
2,459
2,472
2,484
2,496
2,509
2,521
2,534
2,546
2,742
2,754
2,766
2,779
2,791
2,803
2,816
2,828
2,841
2,853
2,753
2,765
2,778
2,790
2,802
2,815
2,827
2,840
2,852
2,864
3,060
3,072
3,085
3,097
3,109
3,122
3,134
3,147
3,159
3,171
3,071
3,084
3,096
3,108
3,121
3,133
3,146
3,158
3,170
3,183
3,378
3,391
3,403
3,415
3,428
3,440
3,452
3,465
3,477
3,490
3,390
3,402
3,414
3,427
3,439
3,451
3,464
3,476
3,489
3,501
$71
$72
$73
$74
$75
$76
$77
$78
$79
$80
$53
$54
$54
$55
$56
$57
$57
$58
$59
$60
$81
$82
$83
$84
$85
$86
$87
$88
$89
$90
$60
$61
$62
$63
$63
$64
$65
$66
$66
$67
2,229
2,241
2,253
2,266
2,278
2,291
2,303
2,315
2,328
2,340
2,240
2,252
2,265
2,277
2,290
2,302
2,314
2,327
2,339
2,351
2,547
2,559
2,572
2,584
2,597
2,609
2,621
2,634
2,646
2,658
2,558
2,571
2,583
2,596
2,608
2,620
2,633
2,645
2,657
2,670
2,865
2,878
2,890
2,903
2,915
2,927
2,940
2,952
2,964
2,977
2,877
2,889
2,902
2,914
2,926
2,939
2,951
2,963
2,976
2,988
3,184
3,196
3,208
3,221
3,233
3,246
3,258
3,270
3,283
3,295
3,195
3,207
3,220
3,232
3,245
3,257
3,269
3,282
3,294
3,306
3,502
3,514
3,527
3,539
3,552
3,564
3,576
3,589
3,601
3,613
3,513
3,526
3,538
3,551
3,563
3,575
3,588
3,600
3,612
3,625
$81
$82
$83
$84
$85
$86
$87
$88
$89
$90
$60
$61
$62
$63
$63
$64
$65
$66
$66
$67
$91
$92
$93
$94
$95
$96
$97
$98
$99
$100
$68
$69
$69
$70
$71
$72
$72
$73
$74
$75
2,352
2,365
2,377
2,396
2,422
2,452
2,473
2,498
2,524
2,549
2,364
2,376
2,395
2,421
2,451
2,472
2,497
2,523
2,548
2,574
2,671
2,683
2,696
2,708
2,720
2,733
2,745
2,757
2,770
2,782
2,682
2,695
2,707
2,719
2,732
2,744
2,756
2,769
2,781
2,794
2,989
3,002
3,014
3,026
3,039
3,051
3,063
3,076
3,088
3,101
3,001
3,013
3,025
3,038
3,050
3,062
3,075
3,087
3,100
3,112
3,307
3,320
3,332
3,345
3,357
3,369
3,382
3,394
3,407
3,419
3,319
3,331
3,344
3,356
3,368
3,381
3,393
3,406
3,418
3,430
3,626
3,638
3,651
3,663
3,675
3,688
3,700
3,712
3,725
3,737
3,637
3,650
3,662
3,674
3,687
3,699
3,711
3,724
3,736
3,749
$91
$92
$93
$94
$95
$96
$97
$98
$99
$100
$68
$69
$69
$70
$71
$72
$72
$73
$74
$75
Page 2
Administration for Children's Services
Division of Child Care
WEEKLY FEE
FULL
PART
TIME
TIME
35% rate above SIS / 17% cap
SIS as of January 2011
March 25, 2011
CHILD CARE FEE SCHEDULE Monthly Incomes
Effective May 2011
MONTHLY GROSS INCOME
FAMILY SIZE=2
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=3
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=4
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=5
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=6
FROM
TO
WEEKLY FEE
FULL
PART
TIME
TIME
$101
$102
$103
$104
$105
$106
$107
$108
$109
$110
$75
$76
$77
$78
$78
$79
$80
$81
$81
$82
2,575
2,600
2,625
2,651
2,676
2,702
2,727
2,753
2,778
2,804
2,599
2,624
2,650
2,675
2,701
2,726
2,752
2,777
2,803
2,828
2,795
2,807
2,819
2,832
2,844
2,857
2,869
2,881
2,894
2,906
2,806
2,818
2,831
2,843
2,856
2,868
2,880
2,893
2,905
2,917
3,113
3,125
3,138
3,150
3,163
3,175
3,187
3,200
3,212
3,224
3,124
3,137
3,149
3,162
3,174
3,186
3,199
3,211
3,223
3,236
3,431
3,444
3,456
3,468
3,481
3,493
3,506
3,518
3,530
3,543
3,443
3,455
3,467
3,480
3,492
3,505
3,517
3,529
3,542
3,554
3,750
3,762
3,774
3,787
3,799
3,812
3,824
3,836
3,849
3,861
3,761
3,773
3,786
3,798
3,811
3,823
3,835
3,848
3,860
3,872
$101
$102
$103
$104
$105
$106
$107
$108
$109
$110
$75
$76
$77
$78
$78
$79
$80
$81
$81
$82
$111
$112
$113
$114
$115
$116
$117
$118
$119
$120
$83
$84
$84
$85
$86
$87
$87
$88
$89
$90
2,829
2,855
2,880
2,906
2,931
2,957
2,982
3,008
3,033
3,059
2,854
2,879
2,905
2,930
2,956
2,981
3,007
3,032
3,058
3,083
2,918
2,931
2,943
2,956
2,968
2,980
2,993
3,008
3,033
3,059
2,930
2,942
2,955
2,967
2,979
2,992
3,007
3,032
3,058
3,088
3,237
3,249
3,262
3,274
3,286
3,299
3,311
3,323
3,336
3,348
3,248
3,261
3,273
3,285
3,298
3,310
3,322
3,335
3,347
3,360
3,555
3,567
3,580
3,592
3,605
3,617
3,629
3,642
3,654
3,667
3,566
3,579
3,591
3,604
3,616
3,628
3,641
3,653
3,666
3,678
3,873
3,886
3,898
3,911
3,923
3,935
3,948
3,960
3,972
3,985
3,885
3,897
3,910
3,922
3,934
3,947
3,959
3,971
3,984
3,996
$111
$112
$113
$114
$115
$116
$117
$118
$119
$120
$83
$84
$84
$85
$86
$87
$87
$88
$89
$90
$121
$122
$123
$124
$125
$126
$127
$128
$129
$130
$90
$91
$92
$93
$93
$94
$95
$96
$96
$97
3,084
3,110
3,135
3,161
3,186
3,212
3,237
3,263
3,288
3,314
3,109
3,134
3,160
3,185
3,211
3,236
3,262
3,287
3,313
3,338
3,089
3,110
3,135
3,161
3,186
3,212
3,237
3,263
3,288
3,314
3,109
3,134
3,160
3,185
3,211
3,236
3,262
3,287
3,313
3,338
3,361
3,373
3,385
3,398
3,410
3,423
3,435
3,447
3,460
3,472
3,372
3,384
3,397
3,409
3,422
3,434
3,446
3,459
3,471
3,483
3,679
3,691
3,704
3,716
3,728
3,741
3,753
3,766
3,778
3,790
3,690
3,703
3,715
3,727
3,740
3,752
3,765
3,777
3,789
3,802
3,997
4,010
4,022
4,034
4,047
4,059
4,072
4,084
4,096
4,109
4,009
4,021
4,033
4,046
4,058
4,071
4,083
4,095
4,108
4,120
$121
$122
$123
$124
$125
$126
$127
$128
$129
$130
$90
$91
$92
$93
$93
$94
$95
$96
$96
$97
$131
$132
$133
$134
$135
$136
$137
$138
$139
$140
$98
$99
$99
$100
$101
$102
$102
$103
$104
$105
3,339
3,365
3,364
3,371
3,339
3,365
3,390
3,416
3,441
3,467
3,492
3,518
3,543
3,569
3,364
3,389
3,415
3,440
3,466
3,491
3,517
3,542
3,568
3,593
3,484
3,497
3,509
3,522
3,534
3,546
3,559
3,571
3,583
3,596
3,496
3,508
3,521
3,533
3,545
3,558
3,570
3,582
3,595
3,607
3,803
3,815
3,827
3,840
3,852
3,865
3,877
3,889
3,902
3,914
3,814
3,826
3,839
3,851
3,864
3,876
3,888
3,901
3,913
3,926
4,121
4,133
4,146
4,158
4,171
4,183
4,195
4,208
4,220
4,232
4,132
4,145
4,157
4,170
4,182
4,194
4,207
4,219
4,231
4,244
$131
$132
$133
$134
$135
$136
$137
$138
$139
$140
$98
$99
$99
$100
$101
$102
$102
$103
$104
$105
Page 3
Administration for Children's Services
Division of Child Care
WEEKLY FEE
FULL
PART
TIME
TIME
MONTHLY GROSS INCOME
FAMILY SIZE=2
FROM
TO
35% rate above SIS / 17% cap
SIS as of January 2011
March 25, 2011
CHILD CARE FEE SCHEDULE Monthly Incomes
Effective May 2011
MONTHLY GROSS INCOME
FAMILY SIZE=3
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=4
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=5
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=6
FROM
TO
WEEKLY FEE
FULL
PART
TIME
TIME
$141
$142
$143
$144
$145
$146
$147
$148
$149
$150
$105
$106
$107
$108
$108
$109
$110
$111
$111
$112
3,594
3,620
3,645
3,671
3,696
3,722
3,747
3,773
3,798
3,824
3,619
3,644
3,670
3,695
3,721
3,746
3,772
3,797
3,823
3,848
3,608
3,621
3,645
3,671
3,696
3,726
3,747
3,773
3,798
3,824
3,620
3,644
3,670
3,695
3,725
3,746
3,772
3,797
3,823
3,848
3,927
3,939
3,951
3,964
3,976
3,988
4,001
4,013
4,026
4,038
3,938
3,950
3,963
3,975
3,987
4,000
4,012
4,025
4,037
4,049
4,245
4,257
4,270
4,282
4,294
4,307
4,319
4,332
4,344
4,356
4,256
4,269
4,281
4,293
4,306
4,318
4,331
4,343
4,355
4,368
$141
$142
$143
$144
$145
$146
$147
$148
$149
$150
$105
$106
$107
$108
$108
$109
$110
$111
$111
$112
$151
$152
$153
$154
$155
$156
$157
$158
$159
$160
$113
$114
$114
$115
$116
$117
$117
$118
$119
$120
3,849
3,875
3,900
3,925
3,874
3,899
3,924
3,937
3,849
3,875
3,900
3,925
3,951
3,976
4,002
4,027
4,053
4,078
3,874
3,899
3,924
3,950
3,975
4,001
4,026
4,052
4,077
4,103
4,050
4,063
4,075
4,087
4,100
4,112
4,125
4,137
4,149
4,162
4,062
4,074
4,086
4,099
4,111
4,124
4,136
4,148
4,161
4,173
4,369
4,381
4,393
4,406
4,418
4,431
4,443
4,455
4,468
4,480
4,380
4,392
4,405
4,417
4,430
4,442
4,454
4,467
4,479
4,491
$151
$152
$153
$154
$155
$156
$157
$158
$159
$160
$113
$114
$114
$115
$116
$117
$117
$118
$119
$120
$161
$162
$163
$164
$165
$166
$167
$168
$169
$170
$120
$121
$122
$123
$123
$124
$125
$126
$126
$127
4,104
4,129
4,155
4,180
4,128
4,154
4,179
4,190
4,174
4,187
4,199
4,211
4,224
4,236
4,257
4,282
4,308
4,333
4,186
4,198
4,210
4,223
4,235
4,256
4,281
4,307
4,332
4,361
4,492
4,505
4,517
4,530
4,542
4,554
4,567
4,579
4,592
4,604
4,504
4,516
4,529
4,541
4,553
4,566
4,578
4,591
4,603
4,615
$161
$162
$163
$164
$165
$166
$167
$168
$169
$170
$120
$121
$122
$123
$123
$124
$125
$126
$126
$127
$171
$172
$173
$174
$175
$176
$177
$178
$179
$180
$128
$129
$129
$130
$131
$132
$132
$133
$134
$135
4,362
4,384
4,410
4,435
4,461
4,486
4,512
4,537
4,563
4,588
4,383
4,409
4,434
4,460
4,485
4,511
4,536
4,562
4,587
4,613
4,616
4,629
4,641
4,653
4,666
4,678
4,691
4,703
4,715
4,728
4,628
4,640
4,652
4,665
4,677
4,690
4,702
4,714
4,727
4,739
$171
$172
$173
$174
$175
$176
$177
$178
$179
$180
$128
$129
$129
$130
$131
$132
$132
$133
$134
$135
Page 4
Administration for Children's Services
Division of Child Care
WEEKLY FEE
FULL
PART
TIME
TIME
MONTHLY GROSS INCOME
FAMILY SIZE=2
FROM
TO
35% rate above SIS / 17% cap
SIS as of January 2011
March 25, 2011
CHILD CARE FEE SCHEDULE Monthly Incomes
Effective May 2011
MONTHLY GROSS INCOME
FAMILY SIZE=3
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=4
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=5
FROM
TO
MONTHLY GROSS INCOME
FAMILY SIZE=6
FROM
TO
WEEKLY FEE
FULL
PART
TIME
TIME
$181
$182
$183
$184
$185
$186
$187
$188
$189
$190
$135
$136
$137
$138
$138
$139
$140
$141
$141
$142
4,614
4,639
4,665
4,690
4,716
4,741
4,767
4,792
4,818
4,843
4,638
4,664
4,689
4,715
4,740
4,766
4,791
4,817
4,842
4,868
4,740
4,752
4,765
4,777
4,790
4,802
4,814
4,827
4,839
4,852
4,751
4,764
4,776
4,789
4,801
4,813
4,826
4,838
4,851
4,868
$181
$182
$183
$184
$185
$186
$187
$188
$189
$190
$135
$136
$137
$138
$138
$139
$140
$141
$141
$142
$191
$192
$193
$194
$195
$196
$197
$198
$199
$200
$143
$144
$144
$145
$146
$147
$147
$148
$149
$150
4,869
4,894
4,893
4,906
4,869
4,894
4,920
4,945
4,971
4,999
5,022
5,047
5,073
5,098
4,893
4,919
4,944
4,970
4,998
5,021
5,046
5,072
5,097
5,123
$191
$192
$193
$194
$195
$196
$197
$198
$199
$200
$143
$144
$144
$145
$146
$147
$147
$148
$149
$150
$201
$202
$203
$204
$205
$206
$207
$208
$209
$210
$150
$151
$152
$153
$153
$154
$155
$156
$156
$157
5,124
5,149
5,175
5,200
5,225
5,251
5,276
5,302
5,327
5,353
5,148
5,174
5,199
5,224
5,250
5,275
5,301
5,326
5,352
5,377
$201
$202
$203
$204
$205
$206
$207
$208
$209
$210
$150
$151
$152
$153
$153
$154
$155
$156
$156
$157
$211
$212
$213
$214
$215
$216
$217
$218
$219
$220
$158
$159
$159
$160
$161
$162
$162
$163
$164
$165
5,378
5,404
5,429
5,455
5,480
5,506
5,531
5,557
5,582
5,608
5,403
5,428
5,454
5,479
5,505
5,530
5,556
5,581
5,607
5,623
$211
$212
$213
$214
$215
$216
$217
$218
$219
$220
$158
$159
$159
$160
$161
$162
$162
$163
$164
$165
Page 5
ATTACHMENT D
Head Start Income Guidelines
ATTACHMENT E
Head Start Statement of Non-Verifiable Income
ATTACHMENT F
Head Start Sample Residency Question
ATTACHMENT G
Head Start Eligibility Verification Form