Service Industry Recovery (SIR) Child Care Form 

SIR addresses the impact of COVID-19 and supports Texas’ continued economic recovery. This child care assistance is for workers in specified industries recognized by the Texas Workforce Commission, including:

Arts, Entertainment, and Recreation

Accommodation and Food Services

Retail Trade

Documentation of work in one of these service industries will be required.

If approved for Service Industry Recovery Child Care, you will receive 12 months of child care eligibility.

To qualify for these services, you must earn less than 75% of the State Median Income (SMI), for example:

$43,549 for a family of 2

$53,796 for a family of 3

$64,043 for a family of 4

Complete the following information for the parent or caregiver who is a Service Industry Worker in need of child care for their child(ren) in order to work.

Name*
Date of Birth*
Are you a current Child Care Services customer? Please place a checkmark by your response below:*
Physical Address*
Mailing Address (if different)
Do you know which facility you would like to use?*
Do your children currently attend this facility?*
Do you have a spouse or is 2nd parent in the home?*
Spouse / 2nd Parent Name*
Spouse / 2nd Parent Date of Birth*
Gender*
Hispanic / Latino*

Which occupation qualifies you as working in the Service Industry Sector? Please place a checkmark by the occupation category that best describes you (only one parent is required to be working in Service Industry Sector):

Please check the occupation category that best describes you below:*

Please submit proof of employment in the qualifying occupation. Examples of acceptable documentation are: 

  • Current paystub (dated in last 30 calendar days).
  • Employment verification form signed by your employer.
  • Signed letter of employment on company letterhead with appropriate company contact information included.
Employer Address*
Does your spouse / 2nd parent work?*
Please check the occupation category that best describes your spouse / 2nd parent below:*
Spouse / 2nd Parent Employer Address *
Consulting the chart below, is your income* at or below these annual or monthly limits based on your family size**?*

If your family income is above the 75% SMI limit, based on the previous chart, you do not qualify for SIR child care and cannot apply for this program.


Family Size
Annual Household Income (Approx. 150% SMI) at or below
Monthly Household Income (Approx. 75% SMI) at or below
2
$43,549
$3,629
3
$53,796
$4,483
4
$64,043
$5,337
5
$74,290
$6,191
6
$84,537
$7,045
7
$86,458
$7,205
8
$88,380
$7,365
9
$90,301
$7,525
10
$92,222
$7,685


If your family income is above the 75% SMI limit, based on the previous chart, you do not qualify for SIR child care and cannot apply for this program.

* Family size consists of parents, those in the home that can be claimed as dependents on a federal tax return, or a minor who is the responsibility of the parent/applicant.

**Income does not include federal or state assistance or child support.  A family’s monthly income is the gross income before adjustments are made for taxes, which can also be referred to as gross earnings or gross pay.

After you submit this form, you will be contacted by Workforce Solutions staff and asked to provide additional personal information over the phone including, but not limited to, gender, social security number, and race/ethnicity.

Complete the section below with information for the child(ren) in need of child care:

First Child's Information

Name*
Date of Birth*
Gender*

Second Child's Information

Name
Date of Birth
Gender

Third Child's Information

Name
Date of Birth
Gender

Fourth Child's Information

Name
Date of Birth
Gender

Fifth Child's Information

Name
Date of Birth
Gender


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?

First Dependent's Information

Name
Date of Birth
Gender

Second Dependent's Information

Name
Date of Birth
Gender

Third Dependent's Information

Name
Date of Birth
Gender

Fourth Dependent's Information

Name
Date of Birth
Gender

Fifth Dependent's Information

Name
Date of Birth
Gender

Signature

By signing this document, you agree to the following statements: 

I certify that I qualify as a Service Industry Worker, require child care to work, my family income is at or below 75% SMI and the address I have provided is my current residential address. I also certify that I am meeting the participation requirements for my household size (25 hrs. per week for single parent/50 hrs. per week for two-parent household).

I understand that child care is only provided for 12 months and I will have to reapply for child care services at the end of the 12-month timeframe. Upon re-applying I may be subject to a waitlist and will not have child care services while on the waitlist or during the eligibility process. 

I certify that all information provided on this form is accurate and child care may be terminated if any of this information is found to be inaccurate. I understand that giving false information may constitute fraud and could result in prosecution and/or repayment of money for services for which I was not entitled.

Documents required to be submitted prior to eligibility determination for SIR child care: 

  • Proof of employment in a qualifying occupation.
  • Proof of citizenship/legal immigration status for children needing care.
  • Completed and signed SIR Child Care Enrollment Form (this application).
Signature
Date*
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