Redetermination Form

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Page 4SECTION I!! - F=AMILY IttffiRM.~I!ONCase Name:~A~ILY SIZE means the applicant (you); the biologicai. step or adoptive parent of any of the applicant's chiidren who~Ive In your home; and your biological or adoptive cnildren under age 21 living in your home. You may also choose to. Include other persons in the home who are related to you by blood or law if they rely on you for more than 500/0 of theirtpport.._What is your family size?How many adults are in ~our family?How many children are in your family?__ How many chi dren are receiving child care? __Co~plete the information below for each child for whom you are seeking child care payments. If needed, attach anadditional paQe.DATEU.S.SOCIALWARD OFFIRST NAME LAST NAME OF M/FETHNICCITIZENSECURITYORIGIN*NUMBERTHE STATEBIRTHYES/NO··(Optional)YES/NO !I:II i• For each child's ETHNIC ORIGIN. list all numbers below that apply: ~Required for Federal Reporting)1 - White 2 - Black or African American 3 - Hispanic or Latino ( ersons declarin~ Hispanic ethnicity should also listtheir race. If you list "3" for a child, also list their race. for example, "3, 1", u3, 2" or "3, I).4 - Asian 5 - American Indian or Alaskan Native 6 - Native Hawaiian or Pacific Islanderu** If NO " . IS entered for U.S. CITIZEN, wnte allen registration number and attach copy of documentation.List all other family members counted in family size: (If more space is needed, please follow this format on a separate sheet of paper)iIFIRST NAMEILAST NAMEDATE OFBIRTHRELATIONSH IPTO APPLICANTSOCIAL SECURITYNUMBER (Optional)IIi 1 IIiI:ISection IV -INCOME INFORMATIONI! Enter the MONTHLY income in each box for all adults age 19 and over counted in family size. If the income does not apply, write UN/A".I IITYPE OF INCOMEiI1. Gross Emr-Ioyment Income: (including tips) from pay stubs before deductions.. Enter any sel -em~loyment income below.i Attach copies of most recent and consecutive pay stubs for each person.$CLIENTOTHER FAMILYMEMBERS$:! 2. Self-Employment Income $ $: 3. Child Support ReceivedI C .: 4. TANF ash ASSistance5. Other Federal Cash Income: For example, Social Security payments and ra.ilroad benefits.I 6. Other Monthly Income: For example. interest income, royalties. pensions. annuities, alimony,ongoing monthly adoption assistance, unemployment compensation, DCFS payments, veteran'spension, survivor's benefits, and permanent disability payments.SUBTOTAL (add lines 1-6)MINUS: Child Support Paid by Applicant's FamilyTOTALL MONTHLY INCOMEI ~ousing Cash Assistance Including Vouchers With S~CifiC Cash Value::For Federal reporting, does not count when totaling onthly Family Income)1 FOR OFFICE USE: PARENT CO-PAYMENTI$$$$$$$$$$$$.__ .$$$ .
Page 5/ SECT!ON V - CHILO"CARE AR.RANGEMENTSCase Name:I - -LIST THE CHILDREN CARED FOR BY EACH PROVIDER If your children go to school, pre-K, or Head Startduring the day, list only the hours that they are with the child care provider. For school age children, list only the)urs that they are in Child Care. (This is not a Provider Change <strong>Form</strong>.)Is one of your providers an approved Head StartlPre-Kcollaboration?#1 Provider Name:~iICHILD'S NAME AGE MON TUE WED THU FRI SAT SUN Provider'sCurrentDaily RateIi #2 Provider Name:!CHILD'S NAMEIIi iIIIIIi #3 Provider Name:CHILD'S NAMEI,iiiI[I!IFROMIampmampmampmampmampmampmampmI II TOtam Ipm iampmampmampmampmampmampmj FROM am am am am am am ampmI Ipm pm pm pm pm pmTO ampmampmampmampmampmampmampmFROMIampmampm IampmampmampmampmampmIIITO am am ~ am am am ampm i pm pm pm pm pm pmIIIFROMIIampmampmampmampmampmampmampmIIIiIiiiI!iIIIAGE iIII TO am I am am am am am amIiI pm pm pmI IiIIIf yes, Collaborator's Name:How long is the program? 0 9mo 0 12mo 0 other_pm pm pm pmI MON 1 TUE WED THU FRI SAT SUNiIiFROM ampm Ii ampmampmampmampmampmampmTO am 1 am am am am am amIFROMI!TOiIIIpm I pm pm pm pm pm pmampm I am am am am am ampm pm pm pm pm pmIampm IiampmampmampmampmampmampmFROM am ! am am am am am am1 pm i pm pm I pm pm pm pm! TOiampm IiI I FROM ampmIIIIiIiAGE!! TOiIIFROMTOFROMTOi FROMiTOIIIampmMONampmampmampmampmampm~~1iIII1IlTUEampmampmampmampmampmampmampmampmampmampmampmampmWEDampmampmampmampmampmampmampmampmampmTHUampmampmampmampmampmampmampmampmampmFRIampmampmampmampmampmampmampmampmampmSATampmampmampmampmampmampmampmampmampmSUNampmampmampmampmampmampmPCovider'surr~ntDally atePCovider'SDal~rrffty ateIiIIII:iI!
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Page 6: Lase Name:SECT!ON VI - CLIFNT CERTI

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