State regulations require a formal application and certification for early learning and care services. This form must be completed by an agency representative in consultation with the family. The agency must certify family eligibility prior to beginning services.
For the first adult living in the same household as the child(ren), complete all items in Section I, including address information. For the purposes of these instructions and the certification of eligibility, a parent/caretaker shall be a person who has responsibility for the child. Thus, “parent/caretaker” could refer, for example, to a biological parent, a stepparent, a grandparent, a foster or adoptive parent, or a legal guardian.
If a second parent/caretaker lives in the same household as the child and is included in the calculation of family size, complete all items in Section I B.
1. Income and Eligibility Information:
Draw your initials below to certify that the total family income stated is true and correct.
For each adult listed in Section I above, enter all of your employer information below.
When a child and his or her siblings are living in a household that does not include their biological, or adoptive parent(s), “family” shall be considered the child and related siblings. List only the children of this” family” who are eighteen and under.
Complete for all children eighteen and under residing in the household
I understand that I am self-certifying single parent status under penalty of perjury.
I understand that as a condition of receiving Emergency Child care services, I am not eligible for 12-month eligibility.
I understand that the information about my eligibility may be reviewed by representatives of the State of California, the federal government, independent auditors, or others as necessary for the administration of the program.
I understand that this certification is not complete until all documentation is submitted and this form has been signed and dated by me and reviewed, signed, and dated by an agency representative.
I certify that my family assets do not exceed $1,000,000; Child Care and Development Block Grant Act Section 658 p (4)(B).
I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
To certify this statement, draw your signature below with your mouse cursor or finger.
certify that I am eligible for COVID-19 Emergency Care as:
1. At-Risk Population
i. Child receiving services from CPS or is at risk of abuse or neglect;
ii. Child eligible through the Emergency Child Care Bridge Program for Foster Children; or
iii. Experiencing homelessness as defined in the McKinney-Vento Homeless Assistance Act
iv. A Child of domestic violence survivors; or
2. An Essential Worker under the California definition of essential worker pursuant to the Governor’s ExecutiveOrder N-33-20, and I am unable to work remotely to complete my job duties and require child care in order to perform the essential work.
3. A parent of a child with disabilities or special health care needs whose individualized education program or individualized family support plans include early childhood education service;
I understand that this self-certification is a requirement for my child/children
to be enrolled in an emergency child care program.
If for any reason this attestation of being an Essential Worker or an At-Risk Population is found to be false or untrue, I understand that I will not have met an eligibility requirement for the receipt of emergency child care and my child may be subject to immediate disenrollment from any program he or she is attending.
By my signature below, I attest that the information provided above is true and correct.