Workforce Solutions of Central TexasWorkforce Specialist/Child Care will attach this addendum to Form 2050Form 2050-A

WORKFORCE SOLUTIONS OF CENTRAL TEXAS

VERIFICATION FORM (Child Care)

PLEASE COMPLETE THE INFORMATION REQUESTED BELOW. FAILURE TO DO SO WILL DELAY YOUR DETERMINATION FOR ELIGIBILITY AND ASSISTANCE MAY BE DISCONTINUED OR DENIED. PLEASE REMEMBER TO SIGN PART D.

This form must be received or prior to ______.

PART A – HOUSEHOLD INFORMATION

Please listevery personthat lives at this address.

Name ( Please Print) /

SSN (optional)

/ D.O.B. /

Relationship

/

Race

/

Child w/

disability
Self (You)
Spouse/Significant Other

Physical Address: ______City/ST______Zip______

Mailing Address: ______City/ST______Zip______

Main Telephone #:______Alternate Phone #: ______E-mail address:______

Please circle one of the following: Never Married Married Separated Divorced Widowed Spouse Incarcerated

Are you a: Veteran (DD214 required) ______or Foster Youth ______or Teen Parent ______?

If you or anyone in your household receives money from the following, please enter the AMOUNT and *submit written proof.

$______TANF$______UNEMPLOYMENT BENEFITS*

$______FOOD STAMPS/SNAP$______CHILD SUPPORT*

$______S.S.I. or SOCIAL SECURITY *$______VETERANS BENEFITS/RETIREMENT*

$______OTHER *$______MONTHLY MEDICAL EXPENSES for a child with disabilities*

PART B – EMPLOYMENT / WAGE VERIFICATION

Your current employer must complete this section and you must submit your FOUR MOST RECENT PAY STUBS or current leave and earning statement (LES) with this form. If you are self-employed, please see theCCS self-employment form. This form must be completed for each place of employment.

Employee’s Name: ______Place of Employment: ______

Date of Employment: ______Average Hours Worked Per Week:______Hourly Pay Rate: $______

How Often Paid? Weekly Every other Week Twice a Month Monthly (Please Circle One)

If your employee is paid a monthly or yearly salary, please indicate amount: $______

If your employee works overtime, please give average hours per month:______Hourly Overtime Rate: $______

If your employee receives any other income, please list (Example: Tips, Commission, Etc…) $______

Signature of Person Providing InformationTitleDate

Business Address Telephone Number
PART C – SCHOOL / TRAINING VERIFICATION

(Parent must provide a copy of current enrollment/class schedule, transcript/semester GPA and degree plan)

This section must be completed by your school official:

Student’s (Parent) Name:______

School /Training Institution: ______

Address of School/Training Institution:______

Telephone Number: ______

Date of Enrollment: ______Degree Plan/Training Plan: ______

On Campus: Total Number of Hours / Semester Hours Currently Enrolled:______Total Lab Hours Required:______

On-Line Classes: Total Number of Hours / Semester Hours Currently Enrolled: ______

Hours / Days of Scheduled Classes: ______Anticipated Graduation/Completion Date: ______

FINANCIAL AID:

Pell Grant Amount: $______Pell Grant Balance: $______

Veterans Benefits Amount: $______

Please List Other Loan Types and Amounts: $______

Signature of Person Providing Enrollment InformationTitleDate
Signature of Person Providing Financial Aid InformationTitleDate
PART D – PARENT SIGNATURE

The parent or caretaker of the child who is receiving Child Care Services must complete this section.

I certify that the above information provided on this form is true and accurate to the best of my knowledge. I understand that giving false information to Workforce Solutions of Central Texas (WSCT) can result in the denial and/or termination of child care and could result in a penalty of waiting 60 days to reapply for services, prosecution and / or the repayment of money for services for which I was not entitled.

I give permission to WSCT to contact a third party to verify that all the information is true and accurate and use the social security numbersfor identification of benefits and income. I release any and all parties providing information to WSCT from any liability associated with the release of such information. I understand that the information I provide is for determiningmy eligibility for childcare services.

Parent / Caretaker SignatureDate

October, 2015