Subsidy, Resource & Referral Program
Subsidy, Resource & Referral Program PRELIMINARY APPLICATION Application No.: ____ NAME OF APPLICANT: __________________________ SS#________________________(required) MAILING ADDRESS: _______________________________________ EMAIL ADDRESS: ______________________________________ TELEPHONE NOS.: ____________________ _________________ ________________ WORK CELL HOME PLACE OF EMPLOYMENT: _______________________________Phone#________________ SCHOOL OR TRAINING PROGRAM: _____________________________________________ ARE YOU A TEEN PARENT? YES NO ANNUAL INCOME: $_____________ CHILD SUPPORT INCOME: $_______________ FAMILY SIZE: _______ Name of the child (ren) requesting assistance Date of Birth 1. 2. 3. 4. 5. Provider of Choice: _______________________________________________________ I hereby certify that the above information is correct and true. I understand that the information will be verified. I also understand that deliberate false information will result in a delay or disqualification of my childcare subsidy. …
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Subsidy, Resource & Referral Program PRELIMINARY APPLICATION Application No.: ____ NAME OF APPLICANT: __________________________ SS#________________________(required) MAILING ADDRESS: _______________________________________ EMAIL ADDRESS: ______________________________________ TELEPHONE NOS.: ____________________ _________________ ________________ WORK CELL HOME PLACE OF EMPLOYMENT: _______________________________Phone#________________ SCHOOL OR TRAINING PROGRAM: _____________________________________________ ARE YOU A TEEN PARENT? YES NO ANNUAL INCOME: $_____________ CHILD SUPPORT INCOME: $_______________ FAMILY SIZE: _______ Name of the child (ren) requesting assistance Date of Birth 1. 2. 3. 4. 5. Provider of Choice: _______________________________________________________ I hereby certify that the above information is correct and true. I understand that the information will be verified. I also understand that deliberate false information will result in a delay or disqualification of my childcare subsidy. ______________________ __________________ Signature of Applicant Date Official use only [ ] ELIGIBILITY [ ] COMPLETED [ ] NO LONGER INTERESTED [ ] NO SHOW [ ] OTHER [ ] INELIGIBILITY [ ] INSUFFICIENT HOURS [ ] NOT IN COMPONENT [ ] OVERQUALIFIED If you are found eligible, you will be placed on the waiting list upon the availability of funds; however, if you are ineligible, you will be notified. Check one Single Married Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 #129 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 772-7147