Application subsidy
1 like568 views
This document appears to be an application for child care subsidy. It requests information such as contact details, marital status, income sources and amounts, child care needs, and consent to verify the provided information. The applicant and their spouse are asked to describe their employment, education, income and child care needs in detail over 4 pages to determine eligibility for subsidy support.
Application subsidy
- 1. First Application Change of Child Care Service Reapplication Change of Income Mailing Address – Please Print Name Street or Box Number City or Town Postal Code Reporting of Constitutional Status is Voluntary: Status Indian = S Non Status Indian = N Inuit = I Metis = M Non-Native = O Saskatchewan Personal Health Number Family Name Given Name Sex M-Male F-Female Birth Date Year Month Day Social Insurance Number(s) Applicant: | | Spouse/Common-Law | | Dependent Children under 18 years-of-age || || || || || || || Correction area – if the above information or your address has been preprinted incorrectly, please list any changes. ANSWER ALL OF THE FOLLOWING QUESTIONS: 1. Please provide the following: Maiden Name: ____________________________ Alias Name: ___________________________ Other Name: ______________________________ 2. Your marital status: Married Single Separated Divorced Widowed 3. Are you living common-law? Yes No (You must answer this question if you are not married.) 4. If your marital status has changed since your last application, give date: |_____|________|______| Year Month Day 5. If you or your spouse/common-law’s income has changed since your last application, please give effective date: |_____|________|______| Year Month Day 6. The Applicant is: 1. Employed (Complete section A) The Spouse/Common-law spouse is: 1. Employed (Complete section A) 2. Self-employed (Complete section B) 2. Self-employed (Complete section B) 3. Seeking employment (Complete section C) 3. Seeking employment (Complete section C) 4. Attending an education facility (Complete section D) 4. Attending an education facility (Complete section D) 5. Special Need (Complete section K) 5. Special Need (Complete section K) 7. Are you or your spouse currently a student on a Study Permit issued by Citizenship and Immigration Canada? Yes No 8. Are both you and your spouse legally able to work in Canada? Yes No Child Care Subsidy Application Are you receiving social assistance payments from the Ministry of Social Services? Please check ( ) if you are receiving a Child Tax Benefit for each child. Yes No For office use only Elig. Start: |_______|_______|_______| Term: |_______|_______|_______| Year Month Day Year Month Day Reason for Child Care: __________________________________________ Case Status: ___________________________ No. of Hol. _____________ Letter Type: ___________________________________________________ Assessor’s Signature: ___________________________ Approved: _______ For Office Use: Case No. daoLesaCnoitacilppAfoepyT Return to: Child Care Subsidy P.O. Box 2405 Stn. Main Regina, SK S4P 4L7 (Page 1 of 4)
- 2. Reason For Child Care Services Applicant Spouse/Common-Law Employed Start Date Year Month Day |_____|________|_____| End Date Year Month Day |_____|_______|______| Start Date Year Month Day |_____|________|_____| End Date Year Month Day |_____|________|_____| Employer Business Phone Number Circle days worked per week. (If you work shifts, part-time or have an undetermined work schedule, please complete section J.) Sun Mon Tue Wed Thur Fri Sat Sun Mon Tue Wed Thur Fri Sat Number of Hours Worked Each Day Self-Employed (If you were self-employed in previous year, please submit your Income Tax Return and Income and Expense Statement) Start Date Year Month Day |_____|________|_____| End Date Year Month Day |_____|________|_____| Start Date Year Month Day |_____|________|_____| End Date Year Month Day |_____|________|_____| Name of Business Business Phone Number Type of Self-Employment Circle days worked per week. (If you work shifts, part-time or have an undetermined work schedule, please complete section I.) Sun Mon Tue Wed Thur Fri Sat Sun Mon Tue Wed Thur Fri Sat Number of Hours Worked Each Day Seeking Employment Last Date Worked or Year Month Day Attended School |_____|_______|_____| Last Date Worked or Year Month Day Attended School |_____|_______|_____| Education/Training School/Facility Name: ____________________________________________ Start Date Year Month Day |_____|________|_____| End Date Year Month Day |_____|________|_____| School/Facility Name: ______________________________________________ Start Date Year Month Day |_____|________|_____| End Date Year Month Day |_____|________|_____| Days Attended Per Week Sun Mon Tue Wed Thur Fri Sat Sun Mon Tue Wed Thur Fri Sat Number of Class Hours Attended in: A.M. P.M. Eve. Child Care Services Required Infant (6 weeks – 18 months) Name(s) Last First Attendance Start Date Name of Child Care Facility No. of Days Required Per Week No. of Hours Required Each Day Total Monthly Facility Fee Preschool Children Name(s) Last First Attendance Start Date Name of Child Care Facility No. of Days Required Per Week No. of Hours Required Each Day Total Monthly Facility Fee Kindergarten Children Name(s) Last First Attendance Start Date Name of Child Care Facility No. of Days Required Per Week No. of Hours Required Each Day Total Monthly Facility Fee School Age Children – (Grade 1 up to and including 12 years of age) Name(s) Last First Attendance Start Date Name of Child Care Facility No. of Days Required Per Week No. of Hours Required Before After School Lunch School Total Monthly Facility Fee A B C D E F G H (Page 2 of 4)
- 3. I. Income Declaration Section Please provide a copy of your most recent paystub(s) for you and your spouse covering the last full month, from ALL sources of income. Complete Applicable: Applicant Spouse/Common-Law 1. Present Month’s Gross Employment Income (before deductions) Applicant Paid – (attach paystub/s) Paid Monthly ______________ / mth Paid every two weeks ______________ / 2 wks Paid weekly ______________ / wk Paid twice per month (eg. 1st & 15th ) _______+______ / mth - Previous month’s employment income ______________ - Does your income fluctuate monthly? Yes No total per month Spouse/Common-law Paid (attach paystub/s) Paid Monthly ______________ / mth Paid every two weeks ______________ / 2 wks Paid weekly ______________ / wk Paid twice per month (eg. 1st & 15th ) _______+______ / mth - Previous month’s employment income ______________ - Does your income fluctuate monthly? Yes No total per month 2. Commission Income: - Submit previous month’s Gross (attach allowable expenses and paystubs if applicable) Applicant – commission total per month Spouse/Common-law - commission total per month 3. Net Income Self-Employment (farm or business) Applicant – Net Income Check ( ) one: Previous Year Current Year Monthly Average Monthly Estimate total per month Spouse/Common-law – Net Income Check ( ) one: Previous Year Current Year Monthly Average Monthly Estimate total per month 4. Student Loan, Training Allowance, Grants, Bursaries or Scholarships Applicant Receives Student Loan __________________ Bursary, Grants, Scholarships for the period of _______ to ________ ________________________________________________ Training Allowance: Paid Monthly ______________ / mth Paid every two weeks ______________ / 2 wks Paid weekly ______________ / wk Child Care allowance ______________ / wk total per month Spouse/Common-law Receives Student Loan __________________ Bursary, Grants, Scholarships for the period of _______ to ________ _________________________________________________ Training Allowance: Paid Monthly ____________ / mth Paid every two weeks ____________ / 2 wks Paid weekly ____________ / wk Child Care allowance ____________ / wk total per month 5. Employment Insurance (attach paystub/s) Applicant Receives Weekly Benefit ________________ Eligible Date |_____|_____|_____| Year Month Day total per month Spouse/Common-law Receives Weekly Benefit ________________ Eligible Date |_____|_____|_____| Year Month Day total per month 6. Rental Income Applicant Receives Income from Room & board __________________ Rental property __________________ _________________ __________________ (other) total per month Spouse/Common-law Receives Income from Room & board ________________ Rental property ________________ _______________ __________________ (other) total per month Applicant receives income from (attach copies) 7. Pensions & Superannuation total per month Spouse/Common-law receives income from (attach copies) Pensions & Superannuation total per month 8. Workers Compensation total per month Workers Compensation total per month 9 Maintenance or Child Support total per month Received: Maintenance or Child Support total per month Received: 10. Other Income ______________________________ (specify) Other Income _______________________________ (specify) PLEASE TURN TO PAGE 4. READ SECTION L AND SIGN IN THE APPROPRIATE SPACE(S). For office use only Assessor’s signature ______________________________________________ Approved by ____________________________________________________ Total Gross family income Number of children x $100 Adjusted family income (a) (a-b)(b) (Page 3 of 4)
- 4. J. Variable Work Schedule/Child Care Requirements: Explain your work schedule providing as much detail as possible (eg. Number of days, hours per day worked, etc.). State the actual weekdays and hours per day that you require child care in one month. K. Special Needs – Child Care Subsidy Referral (MUST BE COMPLETED BY REFERRING PROFESSIONAL) Date: ______________________ Child’s Name: _________________________________________________________________________________ Facility: ______________________________________________________ Child will require child care _____________ days per week. Child will require child care ___________ hours per day. Reason for referral: (if more space is required please provide an attachment). Length of time required: ___________________________________________________________________________________________________ Referring person’s signature: _________________________________________________________________ Date: _________________________ Profession: _______________________________________________________ Name: _________________________________________________ Address: ____________________________________________________________________________ Phone Number: _______________________ L. I state that the information given in this Child Care Subsidy Application is true, correct and complete and that I have not withheld any information which may have an effect on my benefits. I understand I may be liable to criminal prosecution for withholding information or providing false or misleading information. Reporting Requirements I agree to report to the Ministry of Social Services any changes in my circumstances, or the circumstances of my family members, that may affect my eligibility for benefits, or the eligibility of my family members. I understand some examples of such changes are changes in address, income from any source, number of dependents, marital status (including common-law relationships), living arrangements and change in reason for child care services. If I am in doubt as to whether any changes in circumstances will effect my eligibility, I agree to report this to the Ministry of Social Services, Child Care Subsidy office. Client Consent I give my consent to the Ministry of Social Services to obtain and verify information or documents required to confirm my eligibility, or the eligibility of my family members for benefits under the Child Care Subsidy program. I understand information includes income received from any source, employment records, marital status (including common-law relationships), and living arrangements of myself or my family members. I give consent to use my Social Insurance Number and the Health Services Number for myself and all family members for the purposes of administration of the Child Care Subsidy program. I give my consent to any ministry, person, or agency having such information or documents to release them upon written or verbal request to employees of the Ministry of Social Services. I understand examples include, but are not restricted to, information or documents from: the Ministry of Education, Advanced Education, Employment and Labour, Human Resources and Skills Development Canada (Employment Insurance), Workers’ Compensation Board, Saskatchewan Government Insurance, any bank, credit union or other financial institution, any landlord and past employers. I give consent to the Ministry of Social Services to disclose my information to third parties where the information is necessary to verify and confirm my eligibility for benefits or to assist inproviding additional benefits. I understand third party examples include, but are not restricted to the Ministry of Education, Advanced Education, Employment and Labour and other social assistance programs. I give my consent to the Ministry of Social Services to advise my child care facility that my subsidy benefits have been placed on hold. I understand this information may be shared with the facility as my benefits are paid directly to the child care facility on my behalf. Date |____|_____|____| Year Month Day Signature of Applicant Signature of Spouse/Common-law Home telephone number Please be sure address section has been completed correctly on Page 1 7781 Rev.3 06/10 (Page4 of 4)