Subsidy – The Pittsburgh After School Academy

Subsidy Application

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Step 1 of 8

Parent/Caretaker Name:

ELRC Record #:

Permission to Share: Your information will be reviewed and a determination of subsidized eligibility will be made. However, if you are not eligible for subsidized child care, you may be eligible for another Pennsylvania early learning program such as Pre-K Counts, Head Start or Early Head Start.

We are asking your permission to share your application with another Pennsylvania early learning program such as Pre-K Counts, Head Start or Early Head Start if you are not eligible for subsidized child care.

By signing below, you are giving us permission to share your application and all documents you submitted with another early learning program that may meet the child care needs of you and your family.

We will discuss this with you before sharing your information.

I give permission to the reviewer of this application to share my application and all documents I have submitted with one or more of the early leaming programs to determine if I am eligible for their services. I understand that my information will be reviewed again and that the program will contact me in writing or by telephone to inform me of my status or if I need to submit additional information.

I do not give permission to the reviewer of this application to share my application with other early learning programs.

Parent/Caretaker Signature:*

Date:*

Parent/Caretaker Signature:

Date:

Release Of Information: By my signature below, I am giving the ELRC permission to contact reliable sources to verify information. This release is also permitting the ELRC to contact people on my behalf when they are unable to reach me.

I hereby authorize and request the disclosure to the Early Learning Resource Center (ELRC) to contact reliable sources for knowledge of information pertinent to verification of: identity; residence; employment; education and training activities; family size and composition; care and control of child(ren) residing with a grandparent, aunt or uncle; reasons for subsidy suspension; income; and any additional information pertinent to eligibility for the Subsidized Child Care Program for myself and/or those individuals on whose behalf subsidy benefits are paid. I understand that the information obtained will be used only for purposes directly related to the determination or eligibility for the Subsidized Child Care Program.

Parent/Caretaker Signature:*

Date:*

Parent/Caretaker Signature:

Date:

ELRC Representative Signature:

Date:

In the event I cannot be reached, I give the ELRC permission to contact the person(s) identified below:

NAME

TELEPHONE NUMBER

RELATIONSHIP TO YOU

NAME

TELEPHONE NUMBER

RELATIONSHIP TO YOU

NAME

TELEPHONE NUMBER

RELATIONSHIP TO YOU

The above names shall remain active until I contact the ELRC to remove them from my list of alternate contact names.

Parent/Caretaker Name:

ELRC Record #:

Affidavit: An affidavit is a sworn statement of fact. By signing this affidavit, you are saying that the information you entered in this form is true. The affidavit is the legal way to swear that your statements are fact. The parent or person applying for the early learning program should sign and date this application. Your signature validates the information you entered into the form.

I affirm that I have read or have had this application read to me in full and that I have received a written copy of my Rights and Responsibilities form on page 8. All information I have given is true, correct and complete to the best of my ability, knowledge and belief. I understand that the information in this application will be used to determine my eligibility for subsidized child care and may be used for Pre-K Counts, Head Start or Early Head Start, if my permission is given. I understand that information contained in this application may be shared with other Department of Human Services programs and the Office of the Inspector General. Further, I understand that I can be penalized by fine or imprisonment or subsidized child care ineligibility for making false statements or for my failure to report a change that I am required to report. I understand that changes are listed on the subsidized child care Rights and Responsibilities form on page 8. I understand that if I receive child care for which I was not eligible, I will be required to pay back the cost of the subsidized child care I received during the period of time when I was ineligible.

Parent/Caretaker Signature:*

Date:*

Parent/Caretaker Signature:

Date:

ELRC USE ONLY

PELICAN Record #

Meets subsidy requirements effective:

Applicant notified in writing.

Does not meet subsidy requirements effective:

Meets subsidy requirements effective:

Applicant notified in writing.

Reason for ineligibility:

ELRC Representative Signature:

Date:

Date and Time Stamp Application received in ELRC office: