Pennsylvania Application for

Subsidized Child Care

If you want help in paying your child care costs, you must complete this application. This is an
application for subsidized child care. This application is also available in Spanish. If you need
help with reading and/or completing this application, please contact your local ELRC agency.

如果您需要托儿费资助，您必须填写此申请。这是个儿童保育补贴申请。此申请书也有西班牙
文版。如果您需要援助阅读或完成此申请, 请联系您当地的ELRC机构。

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�ក់ជំនួយ���ីលកូន។ �ី�កអ�កត្រូវការជំនួយដ�ើម្បី�ននិង ឬបំ����ក�សំុ�ះ សូមទាក់ទងទីភ្នាក់ងារ
ELRC �ល�ៅ�មមូលដ្ឋានរបស់�កអ�ក។

Eсли вам требуется помощь в оплате детского сада для вашего pебёнка, вы должны
заполнить данную форму. Эта форма - заявление на субсидированное обслуживание
вашего pебёнка в детском саду. Eсли вам нужна помощь в чтении и/или заполнении
данной формы, обращайтесь в бюро ELRC по месту жительства.

Nếu quý vị muốn được trợ giúp chi trả chi phí giữ trẻ cho con quý vị, quý vị phải hoàn tất đơn này. Đây
là đơn xin trợ cấp giữ trẻ. Đơn này cũng có tiếng Tây Ban Nha. Nếu quý vị cần trợ giúp để đọc và/hoặc
hoàn tất đơn này, vui lòng liên hệ cơ quan ELRC tại địa phương của quý vị.

Si necesita ayuda para pagar los gastos de cuidado infantil, complete este formulario. Es una
solicitud para recibir cuidado infantil subvencionado. Si necesita ayuda para leer o completar
esta solicitud, comuníquese con la oficina de ELRC de su localidad.

CY 868 9/18
Parent/Caretaker Name: ELRC Record #:

Subsidized Child Care

The subsidized child care program helps low-income families pay their child care cost. You must live in
Pennsylvania; apply in the county where you live and have a child or children who need child care while you are
working or attending an education or training program.

By completing this application, the Early Learning Resource Center (ELRC) will be able to determine if you and
your family are eligible to receive subsidized funding to help pay for your child care services.

You may submit your completed application by mail, fax or hand-deliver to the local ELRC. If you wish, you may
complete a subsidized child care application on-line at www.compass.state.pa.us.

Note: After you submit your completed application, you will be asked to show documents to verify your
information. The ELRC will let you know the exact information/documents you need and the time period you
will have to submit all required information.

Here are some of the basic requirements:

Residency Do I have to live in Pennsylvania? YES

Do I have to work or train a certain YES - At least 20 hours per week, which can
Employment/Training number of hours per week? include 10 hours of work and 10 hours of training.
or Education Program I am a teen parent; do I have to be If you are a teen parent, you must be enrolled in
enrolled in school? school full-time.

Income Are there income guidelines? Yes - See the inserted chart.

YES - The copay is based on your income

Cost Do I have to pay for child care services?
and family size.

Income Guidelines: The Income Guidelines change every year based on the Federal Poverty Income
Guidelines (FPIG). The inserted chart will show you the maximum amount of income by family size for
subsidized child care. Some family expenses may be deductible.

If you are not sure you meet the income guidelines, please complete the application and we will let you know if
you qualify.

How to complete this application: Please follow the instructions in each section and remember
to sign and date the application affidavit on page 7 before you submit your application. If you need help
completing this application, please contact the ELRC.

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Parent/Caretaker Name: ELRC Record #:

1 Tell us about you: Enter your first and last name, home address, telephone numbers and email address. Please check
the box if you are experiencing homelessness, live in temporary housing, or in a shelter. If so, you can give us a location where we
can send your information or you can pick it up from the ELRC.
Proof of address can be a lease, utility bill, a deed, a rental agreement, state photo ID, driver's license, voter's registration card, or mail
that you have received showing your address.
Benefits Please check yes or no to answer the question if you receive benefits or have received benefits within the last six months such as
TANF cash benefits, Supplemental Nutrition Assistance Program (SNAP) benefits, or housing assistance.

What is your first name? What is your last name? Middle initial:

What is your address? Apt. number:

City: State: ZIP code: On what date did you become a resident of PA?

How can we get information to you if you do not have a permanent address?

If you are experiencing homelessness, live in a

shelter, transitional housing, or share housing because you
cannot afford your own housing, check this box.

What is your telephone number?

What is the primary language spoken in your home?

Cell:
What is the primary language you read in your home?
Home:

What language would you like to receive information in? Work:

What is your military status? Where should we call you if we have any questions?

Non-veteran Veteran Active National Guard/Reserves Cell Home Work

What is your email address? What is the best time to call you?

Benefits:
Yes No Do you currently receive TANF cash assistance?
Yes No Have you received TANF cash within the last six months?
If yes, where? PA Other state:
Yes No Do you currently receive SNAP?
Yes No Do you receive Medical Assistance?
Yes No Do you receive CHIP?
Yes No Do you currently receive housing assistance?
Yes No Do you receive WIC?

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Parent/Caretaker Name: ELRC Record #:

2 List all members of your household and their relationship to you. Enter the first and last
name including the middle initial of all members of your household for whom you are responsible. Enter their date of birth, their
sex M (male) or F (female). If you list your Social Security number (SSN), it will only be used to identify your case. What is the
household member’s relationship to you? Is this family member related to the second adult? Check the race and ethnicity of each family
member; you may select all that apply. (Turn to page 10 to add more names.)
Proof of family composition can include a birth certificate, a custody order, a medical record or a written statement from a physician, or a
school record. If you are a foster parent, you must submit a letter from the county Department of Human Service (DHS) or Children Youth
and Families (CYF) that approves the foster child to be in care.

HOW IS THIS IS THIS PERSON

DATE OF BIRTH SEX ETHNICITY
FIRST NAME, LAST NAME, MIDDLE INITIAL OPTIONAL SSN PERSON RELATED RELATED TO THE
(MM/DD/YY) (M/F) (CHECK ONLY ONE)
TO YOU? SECOND ADULT?

You Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Spouse/Parent of child needing care Hispanic

Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

3 Tell us about your children who need child care services. List the name of your child or
children living in your home who need child care or early learning services. (Turn to page 10 to add more children.)
Check the box Yes or No to answer if your child is a U.S. Citizen or in the United States lawfully and admitted for permanent residence. Check
all days that you need child care services. The ELRC will discuss your child care schedule with you at your face-to-face meeting.

Is the child a U.S.

Check the days that your child needs child care services.
List name of child needing service: Citizen or in the
The ELRC will discuss your child care schedule to make sure you receive the services you need.
U.S lawfully?

1. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

2. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

3. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

4. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

5. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

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Parent/Caretaker Name: ELRC Record #:

Immunization Certificate:
I certify that my child(ren) listed below has/have received their age appropriate immunizations (shots):

I certify that my child(ren) listed below does/do NOT have age appropriate immunizations (shots) because of: Religious beliefs; or
A medical condition of the child.

Parent Signature: Date:

Additional Information About Your Child: Please check all boxes that may tell us about your child: If your child is learning English as a second
language, transfers to different schools because the parent or guardian is a migrant worker, if there is an absent parent who may be incarcerated or
deceased, or if the child was referred by a health/mental health service.

Yes No Are any of the above children learning English as a second language?
If yes, what is the child's name?

Yes No Have any of the above children attended a Head Start or Early Head Start program?
If yes, what is the child's name?

Yes No Have any of the above children been referred to PA Pre-K Counts from another health or mental health agency?
If yes, what is the child's name?

Yes No Have any of the above children moved from one school district to another because their parent or guardian is a migrant worker?
If yes, what is the child's name?

Yes No If any of the above children have an absent parent, is the parent: Deceased In the military Incarcerated (prison)

Not living in the same household Whereabouts unknown

If yes, what is the child's name?

4 Employment/Education/Training: Check Yes or No if you are employed or enrolled in an education or

training program. Please check Yes or No if you need child care while you are working or while you are attending the education or
training program. You must submit proof of the days and hours you are working or enrolled in an education or training program.
Proof of employment/education or training must include a letter or a form (see enclosed) that shows the name of your employer, school
or training program. It should state your actual days and daily schedule (such as Monday - Friday 9 AM - 5 PM) and your total number of
hours weekly. If you are employed, the form should also include how often you are paid: weekly, bi-weekly (26 pays), twice a month (24
pays), monthly or annually. The letter or form must be signed and dated by your employer or authorized school representative.

Is this person self- Does this person need child

EMPLOYMENT Is this person employed?
employed?
Place of employment or self-employment:
care while working?

Yourself Yes No Yes No Yes No

Spouse/Live-In Yes No Yes No Yes No

Parent of Child
Is this person in a training Does this person need child care while attending
TRAINING program?
Place of training:
the training program?

Yourself Yes No Yes No

Spouse/Live-In Yes No Yes No

Parent of Child

EDUCATION - If you are a teen parent:

Yes No Are you enrolled in elementary, middle school, high school, or a GED program?
Yes No Do you need child care while you are attending your education program?

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Parent/Caretaker Name: ELRC Record #:

5 Income and Expenses: Answer the question Yes or No if you or someone in your home receives income (do not list
the earned income of minor children). Check all the boxes of income types that are received. If income you receive is not listed,
write the source in Other. List the name, type of income, amount, and how often the income is received.
Proof of income may include pay stubs showing your gross earnings, an employer statement showing gross earnings and how often you
are paid, a letter from the government agency for SSI or Social Security Benefits, unemployment compensation letter, child support or
alimony letter showing the amount and how often it is paid and if you are self-employed, you may submit your tax returns for the previous
year and all supporting documentation.
Proof of expenses paid out may include medical bills for the last three month period, a court-order for child support payments paid for a
child not living with you or alimony payments.

Yes No Does anyone in your home receive income? If Yes, check all that apply:

Wages SSI Rent Unemployment compensation Child support

Social Security Room and Board Workers Compensation Spousal support Commission
Alimony Union pay Interest Other:

HOW OFTEN DO YOU HOW MUCH INCOME DO DATE LAST

NAME OF PERSON WHO RECEIVES INCOME: TYPE OF INCOME:
RECEIVE INCOME? YOU RECEIVE? RECEIVED:

Do you or your spouse/live-in parent of the child needing care; have medical expenses that were not paid by insurance within the
Yes No past 90 days, which will continue for the next six months? Proof of medical expenses may include doctor bills, hospital bills, dental
bills, health care premiums, bills for medication, prosthetic devices, and/or bills for durable medical equipment.

Do you or your spouse/live-in parent of the child needing care, pay child support or alimony to someone who does not live with
Yes No
you? If YES, attach proof of child support or alimony you are ordered to pay.

Yes No ASSETS: Do you have assets over one-million dollars?

Voter Registration Preference Question (Optional)

If you are not registered to vote where you live now, would you like to apply to register to vote here today?
Yes No OR I am already registered to vote where I live now.

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

To register, you must:

1. Be at least 18 on the day of the next election.
2. Be a citizen of the United States for at least one month PRIOR TO THE NEXT ELECTION;
3. Reside in Pennsylvania and the voting district at least 30 days prior to the next election.

Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this agency.
If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill
out the application form in private. Please contact the ELRC if you would like help. If you believe that someone has interfered with your right to register or
to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political
party or other political preference, you may file a complaint with the Secretary of the Commonwealth, PA Department of State, Harrisburg, PA 17120. (Toll-
free telephone number 1-877-VOTESPA.)

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Parent/Caretaker Name: ELRC Record #:

6 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.

Yes 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
learning 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.

No 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:

7 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

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

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Parent/Caretaker Name: ELRC Record #:

8 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: Applicant notified in writing.

Reason for ineligibility:

ELRC Representative Signature: Date:

Date and Time Stamp

Application received in ELRC office:

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Parent/Caretaker Name: ELRC Record #:

9 Rights and Responsibilities: You have the right to be treated fairly and with respect.
Your rights and responsibilities will be reviewed and discussed with you in detail by a person from the ELRC.

I understand that:
• The information in this form will be kept confidential.

• I may pick any eligible child care provider for my children. An eligible provider meets the requirements of the Subsidized Child Care Program and
agrees to follow the Department of Human Services rules.

• I may need to pick another provider if my provider is not eligible to participate in the Subsidized Child Care Program.

• I will be told in writing when a change causes my family to lose help in paying for child care and that I may ask for hearing if I disagree with a decision
that the ELRC has made.

• I must give the ELRC true and complete information and proof of information as requested.

• I must contact the ELRC within ten days following the date:
- My family’s gross monthly income exceeds income limits based on the flyer the ELRC provided me for reference;
- The child no longer has a need for care or is no longer residing in the household.
- A parent or caretaker in my family becomes an owner or director of a child care facility;
- My family's assets are over $1 million; or
- I adopt my foster child.

• It is important that I contact the ELRC immediately if there is a change to:

- My address;
- My telephone number;
- Who is providing child care for my child(ren); or
- The number of days and hours my child needs care.

After the ELRC has determined you eligible for child care and funds are available to enroll your child(ren) in care, you need to know the following:
1. You must pay a copayment to your provider every week. The copayment is due to the provider on the first day of the week that your child(ren)
attend(s). It is important that you pay your copayment on time. If you do not pay your copayment on time, you may lose the ELRC’s help in paying for
your child care.

2. Unless your child is ill, your child must attend the child care program on all the days that you told the ELRC he/she needed child care. If you need to
make a change due to your work, education or training schedule, you must call the ELRC. You must report to the ELRC if your child will be absent for
more than five days in a row. You could lose the ELRC’s help in paying for your child care costs if your child has excessive, unexplained absences.

3. If your child is absent for more than 40 enrollment days between July 1 and June 30, you will be responsible to pay the provider the daily rate for each
day of absence beginning with the 41st absence. You must pay the provider’s daily rate in addition to your weekly copayment. For example, if
your copayment is $20/week and the daily rate is $20, you must pay $40 for the week that includes your child’s 41st day of absence.

4. The ELRC will pay a child care center, family child care home or a group child care home for up to 15 days when the facility is not open to care
for your child. The ELRC is unable to pay an alternate child care provider during these 15 days when your provider is not open to care for your child.

5. If the ELRC sends you a Notice of Adverse Action, it means there may be a change in your eligibility for subsidized child care. If you do not
understand what is written in the notice, you should contact the ELRC immediately. If you disagree with a decision that the ELRC has made,
you may ask for a hearing to review the decision. You must inform the ELRC that you do not agree with the decision by doing one of the following:
(1) Fill out the bottom part of your notice or write a letter and then mail, fax or take the information to the ELRC; and (2) Call the ELRC to discuss the
reason you do not agree with the decision and follow-up by putting your concerns in writing within seven days following the date of your telephone call
with the ELRC. If you want the ELRC to continue to help pay for your child care during this process, you must mail, fax or take the bottom part of your
notice or the letter that you wrote to the ELRC or call the ELRC on or before the date on the Notice of Adverse Action.

6. You may choose a new provider at any time. However, you must tell the ELRC and the ELRC must issue a new authorization before your child can
begin child care with the new provider. The ELRC will authorize the transfer and continue to help pay for your child care after the transfer if: your
family copayments are up-to-date AND you continue to be eligible for the ELRC’s help in paying for your child care AND the new provider that
you choose meets the requirements of the Subsidized Child Care Program. The new provider must also agree to follow the Department of Human
Services rules. If the ELRC does not authorize the transfer, you will be responsible for paying the total cost of child care at the new provider.

Date discussed with parent/caretaker: Initials of worker:

My signature below confirms that my Rights and Responsibilities were explained to me and that I have received a copy for my records:

Parent/Caretaker Signature: Date:

8
Parent/Caretaker Name: ELRC Record #:

10 Access to Other Services and Information: By answering these questions, we will be able to send you
information about other services you may need.

1. Do you need help finding a quality child care program to meet the needs of your child and family? The ELRC can help you
Yes No
locate a quality child care program.

2. Would you like information about Pre-K Counts? If you have a child between the ages of 3 and 4, you may be eligible for Pre-K
Yes No
Counts. You do not have to be employed to receive Pre-K Counts.

3. Would you like information about Early Head Start or Head Start? If you are pregnant, have a child from birth up to 3 years old,
Yes No you may be eligible for Early Head Start. If you have a child from 3 to 5 years old, you may be eligible for Head Start. You do not
have to be employed to receive Head Start or Early Head Start.

4. Does your child(ren) need health insurance? Pennsylvania's Children's Health Insurance Program (CHIP) provides health
Yes No
insurance to children and teens who are not eligible for or enrolled in Medical Assistance.

5. Would you like information on Pennsylvania's supplemental food program for Women, Infants, and Children (WIC)? If you are
Yes No pregnant, breastfeeding, not breastfeeding, or have an infant or children under age five, including foster children, you may meet
the requirements to receive nutritional support from the WIC program.

Yes No 6. Do you need dental or vision care?

Yes No 7. Do you need health insurance?

8. Would you like information about Pennsylvania's Home Visiting Programs? Home Visiting Programs provide resources and skills
Yes No to help raise children who are physically, socially, and emotionally healthy and ready to learn. If you are: pregnant, an expectant
father, a parent, a caregiver of children, or a member of a family that may be considered at-risk, you may be eligible.

Yes No 9. Would you like information about a child's developmental stages?

Yes No 10. Are you concerned about your child's development?

Yes No 11. Would you like information about high quality child care and Keystone STARS?

Yes No 12. Do you need help paying for food? (SNAP)

Yes No 13. Would you like information about free and reduced school meals?

14. Do you need help paying for your heating, electric, or gas? The Low Income Home Energy Assistance Program (LIHEAP) helps
Yes No
low income families pay their heating bills. The payments would go directly to the utility company if you qualify.

Yes No 15. Do you need information about housing or rental assistance?

Yes No 16. Would you like to take classes to learn English as a second language (ESL)?

Yes No 17. Would you like to enroll in a program to get your high school equivalency diploma (GED)?

Yes No 18. Would you like to enroll in a job training program?

19. Would you like information about the Earned Income Tax Credit (EITC)? You may be eligible for an EITC if you work and earn
Yes No
low to modest incomes. If you are eligible, you may pay less federal taxes, no taxes, or get a refund.

9
Parent/Caretaker Name: ELRC Record #:

Continued from #2 on Page 3: Use this page to list additional children living with you.

HOW IS THIS IS THIS PERSON

DATE OF BIRTH SEX ETHNICITY
FIRST NAME, LAST NAME, MIDDLE INITIAL OPTIONAL SSN PERSON RELATED RELATED TO THE
(MM/DD/YY) (M/F) (CHECK ONLY ONE)
TO YOU? SECOND ADULT?

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Child Hispanic
Non-Hispanic

Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Unknown Other

Continued from #3 on Page 3:

Is the child a U.S.

Check the days that your child needs child care services.
List name of child needing service: Citizen or in the
The ELRC will discuss your child care schedule to make sure you receive the services you need.
U.S lawfully?

6. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

7. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

8. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

9. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

10. Yes No Monday Tuesday Wednesday Thursday Friday Saturday Sunday

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? Did you answer all questions?

? Did you sign and date the Affidavit on Page 7?

Remember: You can mail, hand-deliver,

or fax this application to the ELRC.

CY 868 9/18