APPLY FOR CHILD CARE

Please fill out the following form in its entirety. Please allow yourself enough time to complete it.

What is your preferred choice of communication (you may choose multiple options)?*

Email Phone Mail

Would you like to receive text notifications regarding your status and/or needed paperwork?*

Yes No

(Texts will be sent to your primary phone number listed below.)

Text wfsnetx.CCS to 292929 for text notifications.

Standard data and messaging rates may apply. You may unsubscribe at any time. Text HELP for help or STOP to stop. Max of 30 messages per month. Terms of Use, Privacy Policy

CHILD CARE CUSTOMER RIGHTS AND RESPONSIBILITIES INFORMATION PROGRAM

(WARNING)

FAILURE TO WATCH THE VIDEO ABOVE WILL RESULT IN THE DELAY OF PROCESSING YOUR APPLICATION.

Child Care Customer Rights and Responsibilities:
(WARNING)- FAILURE TO WATCH THE VIDEO ABOVE WILL RESULT IN THE DELAY OF PROCESSING YOUR APPLICATION*

I acknowledge and I am attesting that I have completed the Parent Acknowledgement of Rights and Responsibilities Information Program (Parent Handbook Orientation) in its entirety, all of my questions regarding the child care program were answered by staff of Workforce Solutions Northeast Texas Child Care Services (CCS), and I understood the content of the program. To view the Parent Handbook click here.

APPLICANT INFORMATION

Applicant's Full Name*

First Name

Last Name

Applicant's Social Security Number

Applicant's Gender*

Applicant's Date of Birth*

Applicant’s Highest Educational Level Completed?*

Applicant's Marital Status*

Applicant's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

You may choose multiple options

Applicant`s Ethnicity: Hispanic or Latino?

Yes No

Applicant`s U.S. Citizenship?

Please Select Citizenship Status

Applicant's Physical Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Is your mailing address the same as your physical address listed above?*

Yes No

Applicant's Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Applicant's County*

Applicant's Primary Phone Number*

Applicant's Alternate Phone Number

Applicant's Email Address*

Confirm Applicant's Email Address *

# in household*

APPLICANT'S EMPLOYMENT INFORMATION (IF APPLICABLE)

If you have a future start date please click "yes".

Are you currently employed?*

Yes No

Applicant's Employer's Name*

Applicant's Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Phone*

Hours worked per week*

Hourly Pay Rate* $

Work Schedule*

Hire Date*

Pay Frequency*

Is this job considered self employment?*

Yes No

Do you have a second job?*

Yes No

Applicant's Second Employer's Name*

Applicant's Second Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Phone*

Hours worked per week*

Pay Rate* $

Work Schedule*

Hire Date*

Pay Frequency*

Is this job considered self employment?*

Yes No

Do you have a third job?*

Yes No

Applicant's Third Employer's Name*

Applicant's Third Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Phone*

Hours worked per week*

Pay Rate* $

Work Schedule*

Hire Date*

Pay Frequency*

Is this job considered self employment?*

Yes No

Do you have a fourth job?*

Yes No

Applicant's Fourth Employer's Name*

Applicant's Fourth Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Phone*

Hours worked per week*

Pay Rate* $

Work Schedule*

Hire Date*

APPLICANT'S SCHOOL INFORMATION (IF APPLICABLE)

Is this job considered self employment?*

Yes No

Are you currently enrolled in school?*

Yes No

Are you currently searching for work?*

Yes No

Are you currently registered in workintexas.com?*

Yes No

Documentation of registration will need to be provided*

Understood

Please select check box

You are required to register in workintexas.com and submit documentation of registration.*

Understood

Please select check box

Name of applicant's school*

Address of applicant's school*

Address Line 1

Address Line 2

City

State

ZIP Code

Hours enrolled*

Semester start date*

Program Type*

Training/Certification Degree you are pursuing*

Are you currently enrolled in a second school?*

Yes No

Name of applicant's second school*

Address of applicant's second school*

Address Line 1

Address Line 2

City

State

ZIP Code

Hours enrolled*

Semester start date*

Program Type*

Training/Certification Degree you are pursuing*

Are you currently enrolled in a third school?*

Yes No

Name of applicant's third school*

Address of applicant's second school*

Address Line 1

Address Line 2

City

State

ZIP Code

Hours enrolled*

Semester start date*

Training/Certification Degree you are pursuing*

Program Type*

SPOUSE/SECOND PARENT INFORMATION (IF APPLICABLE)

Do you have a spouse/second parent in the household?*

Yes No

Spouse/Second Parent Name*

First Name

Last Name

Spouse/Second Parents Social Security Number

Spouse/Second Parents Gender*

Spouse/Second Parents Date of Birth*

Spouse/Second Parents Marital Status*

Spouse/Second Parents Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

You may choose multiple options

Is your Spouse/Second Parent a federal or state qualified veteran?*

Yes No

Spouse/Second Parents Ethnicity: Hispanic or Latino?

Yes No

Spouse/Second Parent U.S. Citizenship?

Spouse/Second Parents Primary Phone*

Is your Spouse/Second Parent currently employed?*

Yes No

Spouse/Second Parents Employer's Name*

Spouse/Second Parents Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Phone*

Hours worked per week*

Hire Date*

Pay Rate* $

Work Schedule*

Pay Frequency*

Is this job considered self employment?*

Yes No

Does your Spouse/Second Parent have a second job?*

Yes No

Spouse/Second Parents Second Employer's Name*

Spouse/Second Parents Second Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Phone*

Hours worked per week*

Hire Date*

Pay Rate* $

Work Schedule*

Pay Frequency*

Is this job considered self employment?*

Yes No

Does your Spouse/Second Parent have a third job?*

Yes No

Spouse/Second Parents Third Employer's Name*

Spouse/Second Parents Third Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Phone*

Hours worked per week*

Hire Date*

Pay Rate* $

Work Schedule*

Pay Frequency*

Is this job considered self employment?*

Yes No

Does your Spouse/Second Parent have a fourth job?*

Yes No

Spouse/Second Parents Fourth Employer's Name*

Spouse/Second Parents Fourth Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Phone*

Hours worked per week*

Hire Date*

Pay Rate* $

Work Schedule*

Pay Frequency*

Is this job considered self employment?*

Yes No

Is your Spouse/Second Parent currently enrolled in school?*

Yes No

Is your Spouse/Second Parent searching for work?*

Yes No

Name of Spouse/Second Parents school*

Address of Spouse/Second Parents school*

Address Line 1

Address Line 2

City

State

ZIP Code

Hours enrolled*

Semester start date*

Program Type*

Training/Certification Degree you are pursuing*

Is your Spouse/Second Parent currently enrolled in a second school?*

Yes No

Name of Spouse/Second Parents second school*

Address of Spouse/Second Parents second school*

Address Line 1

Address Line 2

City

State

ZIP Code

Hours enrolled*

Semester start date*

Program Type*

Training/Certification Degree you are pursuing*

Is your Spouse/Second Parent currently enrolled in a third school?*

Yes No

Name of Spouse/Second Parents third school*

Address of Spouse/Second Parent third school*

Address Line 1

Address Line 2

City

State

ZIP Code

Hours enrolled*

Semester start date*

Program Type*

Training/Certification Degree you are pursuing*

Is your Spouse/Second Parent currently registered in workintexas.com?*

Yes No

Documentation of registration will need to be provided*

Understood

Please select check box

You are required to register in workintexas.com and submit documentation of registration.*

Understood

Please select check box

INFORMATION REGARDING EACH CHILD NEEDING CARE

Child's Full Name*

First Name

Last Name

Child's Social Security Number

Child's Gender*

Child's Date of Birth*

Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Child's Age*

Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Child's Ethnicity: Hispanic or Latino?

Yes No

Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a second child?*

Yes No

Second Child's Full Name*

First Name

Last Name

Second Child's Social Security Number

Second Child's Gender*

Second Child's Date of Birth*

Second Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Second Child's Age*

Second Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Second Child's Ethnicity: Hispanic or Latino?

Yes No

Second Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a third child?*

Yes No

Third Child's Full Name*

First Name

Last Name

Third Child's Social Security Number

Third Child's Gender*

Third Child's Date of Birth*

Third Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Third Child's Age*

Third Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Third Child's Ethnicity: Hispanic or Latino?

Yes No

Third Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a fourth child?*

Yes No

Fourth Child's Full Name*

First Name

Last Name

Fourth Child's Social Security Number

Fourth Child's Gender*

Fourth Child's Date of Birth*

Fourth Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Fourth Child's Age*

Fourth Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Fourth Child's Ethnicity: Hispanic or Latino?

Yes No

Fourth Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a fifth child?*

Yes No

Fifth Child's Full Name*

First Name

Last Name

Fifth Child's Social Security Number

Fifth Child's Gender*

Fifth Child's Date of Birth*

Fifth Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Fifth Child's Age*

Fifth Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Fifth Child's Ethnicity: Hispanic or Latino?

Yes No

Fifth Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a sixth child?*

Yes No

Sixth Child's Full Name*

First Name

Last Name

Sixth Child's Social Security Number

Sixth Child's Gender*

Sixth Child's Date of Birth*

Sixth Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Sixth Child's Age*

Sixth Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Sixth Child's Ethnicity: Hispanic or Latino?

Yes No

Sixth Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a seventh child?*

Yes No

Seventh Child's Full Name*

First Name

Last Name

Seventh Child's Social Security Number

Seventh Child's Gender*

Seventh Child's Date of Birth*

Seventh Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Seventh Child's Age*

Seventh Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Seventh Child's Ethnicity: Hispanic or Latino?

Yes No

Seventh Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a eighth child?*

Yes No

Eighth Child's Full Name*

First Name

Last Name

Eighth Child's Social Security Number

Eighth Child's Gender*

Eighth Child's Date of Birth*

Eighth Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Eighth Child's Age*

Eighth Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Eighth Child's Ethnicity: Hispanic or Latino?

Yes No

Eighth Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a ninth child?*

Yes No

Ninth Child's Full Name*

First Name

Last Name

Ninth Child's Social Security Number

Ninth Child's Gender*

Ninth Child's Date of Birth*

Ninth Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Ninth Child's Age*

Ninth Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Ninth Child's Ethnicity: Hispanic or Latino?

Yes No

Ninth Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

Do you need child care for a tenth child?*

Yes No

Tenth Child's Full Name*

First Name

Last Name

Tenth Child's Social Security Number

Tenth Child's Gender*

Tenth Child's Date of Birth*

Tenth Child's relationship to Parent/Caregiver*

If relationship is not Son/Daughter, do you have legal custody or proof of guardianship for this child?*

Yes No

(In order to be eligible for services for this child, you must have legal custody or proof of guardianship.)

This child is not eligible for care.

Tenth Child's Age*

Tenth Child's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Tenth Child's Ethnicity: Hispanic or Latino?

Yes No

Tenth Child's U.S. Citizenship?*

Is this a child of a federal or state qualified veteran?*

Yes No

Does the child have a disability?*

Yes No

Type of Disability*

Type of care needed?*

Is this child currently attending school?*

Yes No

(Head Start, Pre K, or Elementary)

What school are they currently enrolled in?*

When will they start?*

LIST ALL DEPENDENTS IN HOUSEHOLD WHO DO NOT NEED CHILD CARE

Do you have other dependents in the household that you claim on your income taxes who do not need child care?*

Yes No

First Dependent's Name*

First Name

Last Name

First Dependent's Date of Birth*

First Dependent's Gender*

First Dependent's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

First Dependent's U.S. Citizenship?*

How is this person related to you?*

Do you have a second dependent in the household who does not need child care?*

Yes No

Second Dependent's Name*

First Name

Last Name

Second Dependent's Date of Birth*

Second Dependent's Gender*

Second Dependent's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Second Dependent's U.S. Citizenship?*

How is this person related to you?*

Do you have a third dependent in the household who does not need child care?*

Yes No

Third Dependent's Name*

First Name

Last Name

Third Dependent's Date of Birth*

Third Dependent's Gender*

Third Dependent's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Third Dependent's U.S. Citizenship?*

How is this person related to you?*

Do you have a fourth dependent in the household who does not need child care?*

Yes No

Fourth Dependent's Name*

First Name

Last Name

Fourth Dependent's Date of Birth*

Fourth Dependent's Gender*

Fourth Dependent's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Fourth Dependent's U.S. Citizenship?*

How is this person related to you?*

Do you have a fifth dependent in the household who does not need child care?*

Yes No

Fifth Dependent's Name*

First Name

Last Name

Fifth Dependent's Date of Birth*

Fifth Dependent's Gender*

Fifth Dependent's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Fifth Dependent's U.S. Citizenship?*

How is this person related to you?*

Do you have a sixth dependent in the household who does not need child care?*

Yes No

Sixth Dependent's Name*

First Name

Last Name

Sixth Dependent's Date of Birth*

Sixth Dependent's Gender*

Sixth Dependent's Race

Caucasian Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander

Sixth Dependent's U.S. Citizenship?*

How is this person related to you?*

Does your total family assets exceed $1 Million?*

Yes No

Total Household Wages/Salaries from Employment* $

Self Employment Income* $

Interest* $

Dividends* $

Income Earned from Rental Property* $

Retirement* $

SSDI* $

Alimony/Maintenance Payments* $

Worker’s Compensation* $

Refugee Assistance* $

Total Houshold Income* $

CHILD CARE FACILITY INFORMATION

Do you know which facility you would like to use?*

Yes No

Name of child care facility you would like to use:*

Do your children currently attend this facility?*

Yes No

PARENT AGREEMENT: CHILD CARE ATTENDANCE

Please initial below each section to acknowledge you have read and understand each section.
As a requirement for receiving child care services, I agree to the following:

Report Absences:*

I understand if my child is absent for any reason I must contact my child care provider.

Regular Attendance:*

If my child is absent 5 consecutive days my provider will report to WFSNETXCCS of the absence.

Regular Attendance:*

If my provider reports 8 times of 5 consecutive days absence, my child care assistance will end due to excessive absences (40 days).

I acknowledge that I have read and agreed to this parent agreement and all of my questions about this agreement have been answered.*

Have you been enrolled in Child Care Services before?*

Yes No

PARENT ACKNOWLEDGEMENT OF RIGHTS AND RESPONSIBILITIES FOR CHILD CARE ASSISTANCE

Please initial each section to acknowledge you have read and understand each section.

1. Work/Training/Education:*

I understand that I am able to get child care so that I can work, go to school, or be in job training classes. I cannot get child care if I am not working, going to school, or in job training classes for at least 25 hours a week for a one parent household or 50 hours a week for a two parent household. If I have a permant job loss or am no longer enrolled in school, I will notify Workforce Solutions Northeast Texas CCS within 14 calendar days of the change.

2. Family/Income:*

I understand my eligibility for child care is based on my family’s income or size. If my family’s income or size changes, I will notify Workforce Solutions Northeast Texas CCS within 14 calendar days of the change. [For example, if my household income goes over 85% SMI, I have a permanent loss in job or training activities, or move I must report this within 14 calendar days.]

3. False Information:*

I understand if I provide false information to make myself appear eligible for child care services, criminal charges may be filed against me with a local or state prosecuting authority, and my child care may be terminated. I understand I will be responsible for repayment of any amount owed for child care services.

4. Eligibility Validation:*

I understand that information I provide to determine my eligibility is subject to validation through cross-checks against state and federal databases and that I may be asked to participate in face-to-face interviews and provide original documents to verify my identity and eligibility for child care services.

5. Reporting Changes:*

I understand it is my responsibility to report true and correct information to Workforce Solutions Northeast Texas CCS within 14 calendar days. I understand it may be considered stealing child care services if I continue to receive child care without notifying Workforce Solutions Northeast Texas CCS within 14 calendar days of any permanent changes in my work, training, or education status; my income goes over 85% SMI, my houshold size changes or if I move. I understand if I fail to notify Workforce Solutions Northeast Texas CCS within 14 calendar days for any of the changes in status discussed above, criminal charges may be filed against me with the Texas Workforce Commission, my child care may be terminated, and I may have to repay the amount owed. I understand that submission of forms does not represent notification of changes. I will contact Workforce Solutions Northeast Texas CCS via phone at 903-794-8999, via email at ccs@netxworks.org or though their website at www.netxworkforce.org

6. Parent Handbook:*

I acknowledge I have received the link to the Parent Handbook with all requirements to receive child care assistance in the email I received to set up this account. I understand I am responsible for adhering to all the requirements in the Parent Handbook and that I can review the handbook at any time online.

I UNDERSTAND:

Please initial each section to acknowledge you have read and understand each section.

1. A person who obtains or attempts to obtain, by fraudulent means, services to which the person is not entitled may be prosecuted to the fullest extent under applicable state and federal laws;*

2. I am entitled to be notified about my eligibility for services within 20 calendar days from when my completed paperwork and required documents are received;*

3. I, or my representative, may appeal a denial, reduction, or termination of services;*

4. Services will be provided without regard to sex, race, color, religion, national origin, political affiliation or belief, age or disability;*

5. The information on this application is confidential;*

6. By signing this form, I am applying for services from Workforce Solutions Northeast Texas CCS.*

7. I understand I cannot reapply for child care services for 60 days if my child has 40 or more absences within my 12 month eligibility period or if I fail to pay my parent share of cost.*

8. I give permission to Workforce Solutions Northeast Texas CCS to contact a third party to verify income or family size, citizenship and age of my children in need of childcare assistance, and use the Social Security numbers listed for identification and verification of all public benefits and income.*

9. All information provided represents a complete and accurate statement of my family’s circumstances at the time of application. I agree to report any changes to this information within 14 calendar days of the change.*

SIGNATURE

By typing my name in the box below, I sign and certify that I have read and agree to the statements above.*

Spouse/Significant Other Signature*

Babel Notice:

This document contains vital information about requirements, rights, determinations, and/or responsibilities for accessing workforce system services. Language service, including the interpretation/translation of this document, are available free of charge upon request.

Este documento contiene información imortante sobre los requisitos, los derechos, las determinaciones y las responsabilidades del acceso a los servicios del sistema de la fuerza laboral. Hay disponibles servicios de idioma, incluida la interprectación y la traducción de documentos, sin ningún costo y a solicitud.

EQUAL OPPORTUNITY IS THE LAW

Workforce Solutions Northeast Texas dba Workforce Solutions is an equal opportunity employer/program and auxiliary aids and services are available upon request to include individuals with disabilities. TTY/TDD via RELAY Texas service at 711 or (TTD) 1-800-735-2988 (voice).