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Childcare Assistance Application

Please complete the following application and attach any additional documentation requested. If the space provided is inadequate, please attach as may additional pages with responses as necessary. Additional documents may be requested before your application is proceeds.

Applicant Name*

Answer Required

Name of Student(s) Attending Vega*

Answer Required

Relationship to Student(s)*

Answer Required

Adress*

Answer Required

Phone Number*

Number Required

Please list everyone living in your household. *

Answer Required

Household Current Gross Monthly Income*

Answer Required

Total monthly expenses for your household. *

Answer Required

Please provide a brief description of your situation and your need. Include how much you are requesting to cover childcare related expenses. *

Answer Required

Please intitial the following:

I certify that the student(s) listed in this application reside full-time in my home. *

Answer Required

I certify that I/my household recently experienced a financial hardship, specifically ___________________________________________________________ (in the space below please fill in the blank and initial)*

Answer Required

Federal Poverty Line

Members of Household:
1	$12,760
2	$17,240
3	$21,720
4	$26,200
5	$30,680
6	$35,160
7	$39,640
8	$44,120

For families/households with more than 8 persons, add $4,480 for each additional person.

I certify that my household is currently earning less than the federal poverty line as described by the U.S. Department of Health and Human Services. *

Answer Required

I certify that I'my household have exhausted all existing financial resources at my disposal, including without limitation any savings, proceeds from the sale of expendable assets, and/or insurance proceeds.*

Answer Required