"Employment Verificaton Letter, Proof of Income"
Dear Parent or Guardian, Attached is the Head Start Pre-Application Packet that you requested. All families must complete the pre- application form and the Family Income Worksheet. Families who are homeless must also complete the Homeless Questionnaire on the back of the Family Income Worksheet. Please fill out all forms completely and include proof of the child’s date of birth, proof of income, and the child’s immunization records. All incomplete applications will be returned. Families who are homeless do not have to provide proof of income and may apply without proof of the child’s date of birth or immunization records if they are not available. A completed pre-application packet should include the following: The completed pre-application form. Be sure to sign and date on the back. A copy of the child’s birth certificate. If you do not have the birth certificate, we will accept a hospital birth record or a copy of an Oregon Health Plan medical card as a substitute. Children must be born between September 2, 2003 and September 1, 2005 to qualify. The completed Family Income Worksheet. The completed Homeless Questionnaire, if the family is homeless. The child’s immunization records. Proof of the parent/guardian’s income: Proof of current Temporary Assistance to Needy Families (TANF) – Cash grant Proof of current Employment Related Daycare assistance (ERDC) Proof of current Supplemental Social Security Income (SSI) Homeless families do not need to provide proof of income. Foster parents need only provide a copy of the child’s placement letter from DHS Child Welfare. If you do not receive any of the above, please submit proof of income for the last 12 months or last calendar year. Items that can be used as proof of income are: Tax returns W2 forms Pay stubs Reported Income Display printout from Department of Human Services (if you receive food stamps or TANF payments) Financial aid award letters Unemployment Statements Copies of child support awards or checks Certain types of military pay are exempt, please call if you need information. If your child has special needs, please provide documentation you have concerning them. This may be information from a doctor or special services provider. After we receive your pre-application, it will be processed and scored based on your child’s needs and your family income. Completing this pre-application does not guarantee your child a place in the classroom. Children are selected based on their overall score. If you have questions about the pre-application process, please call (503)581-1152. Completed pre-application packets should be mailed or brought to: Community Action Head Start 2475 Center St NE Salem, OR 97301 The United States Department of Agriculture (USDA) and the State of Oregon prohibit discrimination in all USDA programs and activities on the basis of race, color, national origin, sex, religion, age or disability. Family Income Worksheet To be completed and attached to the Pre-Application Step 1 Is your family currently homeless? (see Homeless Questionnaire on the back of this form) Yes If yes, complete Homeless Questionnaire on back of form and go to step 7 No If no, go onto step 2 Step 2 Does your family receive SSI (Supplemental Social Security Income)? Yes If yes, attach proof of SSI and go to step 7 No If no, go onto step 3 Step 3 Does your family receive TANF (Temporary Assistance to Needy Families) or Employment Related Daycare (ERDC) ? Yes If yes, attach current proof of TANF and/or ERDC and go to step 7 No If no, go onto step 4 Step 4 Is the child in a state approved foster care placement? Yes If yes, attach proof of foster placement from DHS , and go to step 7 No If no, go onto step 5 Step 5 Check the boxes for all the proof of income you are sending with your application. Income can be for the past 12 months or the last calendar year. All income must be reported for all parent/guardians who are living with the child. You do not need to report income of other family members who live in the household, or for a parent/guardian who does not live with the child. If you had no income for the past 12 months or last calendar year, go to step 6. Tax Return W2 form(s) Pay stubs (for all pay periods during the past 12 months or last calendar year) Food Stamp Income History report (FSRN) from DHS Unemployment statement or pay stubs Child support statement or pay stubs Financial aid or scholarship award letters Alimony statement or pay stubs Other (specify): ___________________________________________ Step 6 If you had no income for the past calendar year or last 12 months, please write in the space below what the circumstances were and how you and your child were supported during this time. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Step 7 Sign and date to indicate that you declare the above information to be true and correct, and that you have reported all income for the designated period for all parent/guardians who live in the household with the child. Print Name: __________________________________________________________________________ Signature: ____________________________________________ Date: _________________________ Homelessness Questionnaire for Head Start Eligibility Families who are currently homeless are income eligible for Head Start services and are not required to provide any proof of income. You must be currently homeless at the time of application and meet the federal definition of homelessness from the McKinney-Vento Homeless Assistance Act. To determine if you are considered homeless for the purpose of this Head Start application please check the box to indicate your current living situation: We live in transitional housing, and must move out of this housing within two years. What program placed you in the transitional housing? ________________________ We are staying with friends, family or someone else because we lost our home or cannot afford a home. We will be able to stay there until we find stable housing. How long have you been staying there? _________________________ Why are you staying there (what caused you to move in)? _____________________ How long can you stay there? ________________________ We are staying with friends, family or someone else because we lost our home or cannot afford a home. We will only be able to stay for a short time (one month or less). How long have you been staying there? _________________________ Why are you staying there (what caused you to move in)? _____________________ How long can you stay there? ________________________ We move around frequently staying with various friends or relatives because we lost our home or cannot afford a home. We are staying in a motel or hotel because we lost our home or cannot afford a home. We are staying at a homeless shelter or domestic violence shelter. Which shelter? __________________________ Can we call to confirm? Yes No We are sleeping at night in a building or home that is not meant for people to sleep in. This includes garages, barns, parks, public place, abandoned building, bus or train station, or condemned homes or homes that do not have necessary services such as heat or water. Please describe: _______________________________________________________ We are camping in a tent, motor home, trailer, van, car or other vehicle. We do not have a place to sleep at night. If you cannot check any of the boxes above, you probably do not meet the definition of homeless. You may still apply for Head Start services, but will be required to provide proof of income. Please complete the Family Income Worksheet on the other side of this form, and include copies of your proof of income with the application. Head Start Combined Pre-Application for 2008-2009 School Year Community Action Head Start & Salem-Keizer Head Start Child’s Name: __________________________________, _________________________ _____ Last First M. I.. Date of Birth: ____/____/____ Male Female Primary Language: _________________________ Second Language: ___________________________ Does your child need an interpreter? Yes No Living Address: ________________________________________ __________________ ___________ Street City Zip Code Is this also the address for mailing? Yes No If no, list additional address below. Is this also the address for school bus pick up/drop off? Yes No If no, list additional address below. Mailing Pick Up/Drop Off _____________________________________ ____________ _________ Street City Zip Code Mailing Pick Up/Drop Off _____________________________________ ____________ _________ Street City Zip Code Home Telephone: ________________________ Message Telephone: ___________________________ Disability Status: Diagnosed Disability Suspected Disability Is child receiving early intervention services (ECSE)? Yes No If yes, name of specialist: ______________________________________________ Parent/Guardian Name: ________________________________, _________________________ ______ Last First M.I. Date of Birth: ____/____/____ Male Female Relationship to Child: Parent Step-Parent Foster Parent Other Relative Legal Guardian Living with Child? Yes (lives in household or temporarily absent) No (permanently absent) If no, indicate address below Address: _______________________________________________ __________________ ___________ Street City Zip Code Telephone Numbers: _____________________ ____________________ _____________________ Home Work Cell Message Home Work Cell Message Home Work Cell Message Primary Language: _________________________ Second Language: ___________________________ Does parent/guardian need an interpreter? Yes No Employment Status: Employed Full Time (32 hours per week) Employed Part Time Student Homemaker Unemployed Other (specify): ____________ Name of Employer: ____________________________________________________________________ Parent/Guardian Name: ________________________________, _________________________ ______ Last First M.I. Date of Birth: ____/____/____ Male Female Relationship to Child: Parent Step-Parent Foster Parent Other Relative Legal Guardian Living with Child? Yes (lives in household or temporarily absent) No (permanently absent) If no, indicate address below Address: _______________________________________________ __________________ ___________ Street City Zip Code Telephone Numbers: _____________________ ____________________ _____________________ Home Work Cell Message Home Work Cell Message Home Work Cell Message Primary Language: _________________________ Second Language: ___________________________ Does parent/guardian need an interpreter? Yes No Employment Status: Employed Full Time (32 hours per week) Employed Part Time Student Homemaker Unemployed Other (specify): ____________ Name of Employer: ____________________________________________________________________ Family Type: Two Parents Single Parent Other Relative Legal Guardian Foster Home (DHS Caseworker: _________________________________________) How many people are in your family and live in your household? _____ How many are adults? _____ How many are children? _____ Have you made a migratory move within the last 12 months because of agricultural work? Yes No Does your family receive: Cash public assistance (TANF)? Yes No Child Support? Yes No Employment Related Day Care (ERDC)? Yes No Who referred you to Head Start? _________________________________________________________ Has your child ever received Head Start services? Yes No If so, where? _____________________ Has your child ever received special services? Yes No If so, where? ________________________ Please attach documentation if available Full day, full year services are offered in Salem by Community Action Head Start to parents who work full time. If you work at least 32 hours per week and are interested, check this box Full day, school year services are offered in Salem by Community Action Head Start to parents who attend school full time (12 credit hours). If you are a full time student (not GED or ESL), and are interested, check this box SPECIAL CONCERNS (Check all that apply): This information is used to determine the needs of your child, and will not be shared with any other agency. All information you give to Head Start is confidential. Family Homeless (Please complete Homelessness Questionnaire) Parent has a diagnosed disability Parent incarceration/parole/probation Parent gang participation Parent does not have high school diploma or GED Parent cannot read or write in any language Parent was under age 18 at the time of this child’s birth Parent has drug or alcohol issues Child Physical Development ________________________ Health Concerns _____________________ Behavioral Concerns _________________________ Currently receiving mental health counseling Child has experienced or witnessed emotional/physical abuse If you have other concerns that you would like us to consider, please attach a letter describing them. I declare the above information is true to the best of my knowledge. I understand this is a pre-application and does not guarantee enrollment in the Head Start program. I understand that pre-applications received will be scored based on family circumstances and that children will be placed in the program according to their scores. I understand that this pre-application is used jointly by Community Action Head Start and Salem-Keizer Head Start, and authorize each program to refer this pre-application and attached supporting documents to the program that is appropriate for my family’s needs and geographic location. Parent/Guardian Signature: ______________________________________________ Date: _____________ ATTACHED: INCOME VERIFICATON FROM THE FAMILY INCOME WORKSHEET BIRTH CERTIFICATION (OR APPROVED SUBSTITUTE) FOR CHILD CHILD’S IMMUNIZATION RECORDS FAMILY INCOME WORKSHEET MAIL COMPLETED PRE-APPLICATION AND ATTACHMENTS TO: Community Action Head Start 2475 Center St NE Salem, OR 97301 (503)581-1152