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DIVISION OF WELFARE AND SUPPORTIVE SERVICES Child Care (State of Nevada, Department of Information Technology)

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DIVISION OF WELFARE AND SUPPORTIVE SERVICES
Child Care and Development Program
The Division of Welfare and Supportive Services (DWSS) works in partnership with The Children’s
Cabinet and the Las Vegas Urban League to provide child care assistance to low income families so
that parents can work. The Child Care and Development Program (CCDP) pays a portion of child
care costs for eligible families based on household income and family size. Anyone can apply for
child care assistance and receive a formal evaluation.
How to Apply
You can contact any of the following locations in person, by phone, fax, or email to apply for
assistance or receive more information about our program. Additionally, you may apply for assistance
online via Access Nevada at https://accessnevada.dwss.nv.gov
.
In Southern Nevada
ADMINISTRATION
2470 N. Decatur, Ste. 150
Las Vegas, NV 89108
Phone: (702) 473-9400
Toll Free: (855) 4UL-KIDS
Fax: (702) 405-8583
Eligibility Fax: (702)410-9906
Email: childcareinfo@lvul.org
FLAMINGO OFFICE
3320 E. Flamingo Rd
Suite #49
Las Vegas, NV 89121
Phone: (702) 473-9400
Fax: (702) 331-1417
In Northern Nevada
ADMINISTRATION
1090 S. Rock Blvd.
Reno, NV 89502
Phone: (775) 856-6210
Fax: (775) 856-6208
Toll Free: 1-800-753-5500
Email: mail@childrenscabinet.org
RENO OFFICE
4055 S. Virginia St
Reno, NV 89502
Phone: (775) 746-5511
Fax: (775) 746-5530
CARSON OFFICE
2527 N. Carson St. Ste. #255
Carson City, NV 89706
Phone: (775) 684-0880
Fax: (775) 887-1365
Toll Free: 1-866-434-2221
Help Finding a Child Care Provider
Quality child care supports your child’s growth and school readiness. If you need help f inding a
quality child care provider or other resource, contact one of our Child Care Resource and Referral
program staff members by calling The Children’s Cabinet or the Las Vegas Urban League (listed
above).
KEEP THIS PAGE FOR YOUR RECORDS
2151-WC-A (9/19)
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
Child Care and Development Program
Application for Child Care Assistance
“Working for the Welfare of ALL Nevadans”
Who Can Apply
Anyone can apply for child care assistance for their child. No person will be discriminated against for any reason (such as race, age,
color, religion, sex, disability, political belief, sexual orientation, or national origin) in any Division of Welfare and Supportive
Services (DWSS) program. To file a complaint, please contact the Chief of the Child Care and Development Program (CCDP)
located at 1470 College Parkway, Carson City, Nevada 89706. You can also file a complaint at any DWSS district office or child care
office and your complaint will be forwarded to the Child Care Chief.
Eligibility
The following must be verified to see if you are eligible for Child Care Assistance.
●
Proof of:
• Citizenship for all children applying for child care;
• Identification for all adult household members;
•
Nevada residency;
•
All income;
• Relationship for all household members;
• Custody;
●
Purpose of Care – every required adult (and minor parent) must be in an approved activity, such as working, looking for
work, going to school or training, participating in DWSS approved activities related to preparation for employment, or
other activities authorized by the CCDP;
• Documentation for any child(ren) in your home who has a special need.
Social Security Numbers
You will be asked to provide Social Security Numbers (SSN) for all persons (including yourself) who are applying for assistance;
SSNs are used to verify your income and resources and to conduct computer matching with other agencies. It is also used to gather
workforce information, conduct investigations, recover overpaid benefits and to ensure duplicate benefits are not received.
Providing or applying for a SSN is voluntary. You are not required to provide a social security number and your eligibility will not
be denied due to the failure to provide a SSN for required household members. If you do not want to provide your social security
number, please write “refused” in the social security number fields on the application. If you provide a social security number on
the application, you must provide verification.
Selection of a Child Care Provider
You must also select a child care provider that meets the needs of your family. Parents are encouraged to work with the Child Care
Resource and Referral and to visit more than one provider before making a decision. Your provider must meet the following:
●
Must not be the natural or adoptive parent or guardian to the child, whether or not they live with the child;
●
Must not live in the same house as the child;
●
Must not have an active child care case for their own child(ren);
●
Providers must be enrolled with the CCDP and in good standing;
Important Information – The CCDP may send information that requires you to respond. You should make arrangements for your
mail if you are away from home so you can respond by the due date. If you do not respond by the due date and/or we lose contact
with you, your case may be terminated.
Special Accommodations
This application is available in English and Spanish. Please contact us if you need a Spanish version or an interpreter.
Acomodaciones Especiales
Esta solicitud está disponible en inglés y español. Por favor comuníquese con nosotros si necesita una versión en español o un
intérprete.
2151-WC
(
01
/
18)
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
Child Care and Development Program
FILL IN ALL BLANKS FOR EVERYONE WHO CURRENTLY LIVES IN THE HOME WITH YOU,
WHETHER YOU CONSIDER THEM HOUSEHOLD MEMBERS OR NOT
.
If you need additional space, please use a second
application or separate piece of paper.
P
L
EA
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/
E
T
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FO
R
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A
CH
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E
H
O
L
D
M
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M
B
E
R
I
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THE BOXES BELOW:
E
t
hn
i
ci
ty
:
H
=
H
i
spani
c
/
La
t
i
no
N
=
N
on
-
H
i
spani
c
/
La
t
i
no
Race: A–Asian; B–Black or African American; I–American Indian or Alaska Native; N–Native Hawaiian or Pacific Islander; W–White
Marital Status
:
S
–
Single;
M
–
Married;
N
–
Separated;
D
–
Divorced;
W
–
Widowed
ADULTS:
Legal Name
Relationship
to You
Self
S
e
x
Date of
Birth:
State or
Country
of Birth
Social Security Number Race Ethnicity
Marital
Status
CHILDREN (Under the age of 18):
Legal Name
Relationship
to You
S
e
x
Date of
Birth
State or
Country
of Birth
US
Citizen
Y/N
Social Security Number Race Ethnicity
Need
Child
Care?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Home Address City State Zip
Mailing Address
City State Zip
Phone Home Work Cell Phone Home Work Cell
E-Mail Address
Please Answer the Following Questions About Your Household:
1. Is your Family Homeless (lack a fixed, regular, and adequate nighttime residence)? Yes
If Yes, Please Explain:
2. Is any household member in the Military? Yes
If Yes, Name: Active Duty or Reserve?
3. Is any adult (or minor parent) in your household unable to work and/or attend a training program? Yes
If Yes, Name: Reason:
4. Do any of the children in the household have special needs? Yes
If Yes, Name: Reason: Current IEP or IFSP for child? _
Name:
2
2151-WC(01/18)
Reason: Current IEP or IFSP for child? _
Name: Reason: Current IEP or IFSP for child? _
5.
Is any household member, including a minor child, temporarily out of the home? Yes No
If Yes, Name: Reason: Expected date of Return:
6.
Is any household member pregnant? Yes No
If Yes, Name: Anticipated Delivery Date:
7.
Has any household member received TANF cash benefits? Yes No
If Yes, Name: When: Where:
8.
Is anyone currently disqualified from any DWSS program for an intentional program violation (IPV)? Yes No
If Yes, Name: Program: Start Date:
9.
Does your household have assets with a value over one million dollars ($1,000,000)? Yes No
If Yes, Name: Type of Asset:
10.
Do you expect any other changes in the next six (6) months? Yes No
If Yes, Please Explain:
11.
Is anyone paying all or part of your expenses (rent, utilities, child care, etc.) for you? Yes No
If Yes, who: Amount paid: How Often:
Are you expected to repay this money? Yes No
12.
Are both parents of the children living in the home? Yes No
I
f
N
o
,
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e
Co
mp
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Pa
ge
s
,
i
f
N
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c
e
ss
a
r
y
.
Child’s Name
Name and Address of Parent
not residing in the Household
Name:
Address:
Phone: ( )
Receive Child
Support?
Yes
No
Amount
Weekly
How Often
Bi-weekly
Semi-monthly
Monthly
Received through
which medium?
D.A.’s Office
Court Agreement
Private Agreement
Name:
Address:
Phone: ( )
Yes
No
Weekly
Bi-weekly
Semi-monthly
Monthly
D.A.’s Office
Court Agreement
Private Agreement
Name:
Address:
Phone: ( )
Yes
No
Weekly
Bi-weekly
Semi-monthly
Monthly
D.A.’s Office
Court Agreement
Private Agreement
I
N
CO
M
E
/
BE
N
E
FI
TS
(
O
THE
R
T
H
A
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E
M
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T
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:
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a
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a
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f
i
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me
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i
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d
i
n
t
h
e
p
r
e
v
i
o
u
s
30
day
s
01– TANF
02– SNAP
03– Housing Assistance
04– Foster Care Payments
05– Veteran’s Benefits
06– Lump Sum Payments
07– Military Allotments
08– Worker’s Compensation
9
– Temporary Disability Insurance
10
–
Ed
u
ca
t
i
ona
l
Ass
i
s
t
a
nc
e
/
Pe
ll
G
r
a
nt
s
11 – Unemployment
12 – Contributions or Loans
13 – Railroad Retirement
14 – Insurance Settlements
15– WIC
16
– Tips
17
– Dividends
18
– Royalties
19
– Interest
20
– Winnings
21
– Alimony
22 - Supplemental Security Income (SSI)
23 – Social Security Disability Benefits
24 – Social Security Survivors Benefits
25 – Social Security Retirement Benefits
26
– P
e
n
s
i
on
s
/
Re
t
i
r
e
me
n
t
Tr
u
s
t
s
27 – Adoption Subsidies
28 - Medicaid
Other:
Income
Type #
Who Receives
the Income
Amount How Often
Income
Type #
Who Receives
the Income
Amount How Often
3
2151-WC(01-18)
EMPLOYMENT:
Please list current employer
and
any employer each household member has worked for since your last application for child care assistance. This includes
self-employment, in-kind activities and odd jobs.
Household
Member
S
ta
r
t
D
a
te
/
End Date
Employer Name
Address and Telephone Number
Name:
Address:
Phone:
( )
Average
Weekly
Hours
Rate of
Pay
How Often
Paid
Weekly
Bi-weekly
Semi-monthly
Monthly
Commission
S
c
h
e
du
l
e
/
S
h
i
f
t
Schedule:
Varies
Mon
Tue
Wed
Thu
Fri
Sat
Sun
From:
To:
Name:
Phone:
( )
Weekly
Bi-weekly
Semi-monthly
Monthly
Commission
Schedule:
Varies
Address:
Mon
Tue
Wed
Thu
Fri
Sat
Sun
From:
To:
T
R
A
ININ
G
/
E
D
U
C
A
T
IO
N
:
I
f
an
y
o
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adu
lt
s
i
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e
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o
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s
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a
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e
s
t
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n
t
s
pa
r
t
i
c
ipa
t
i
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g
i
n
a
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ai
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i
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p
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o
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r
a
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o
r
a
tt
e
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di
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c
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a
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c
o
mp
l
e
t
e
t
h
e
f
o
ll
o
wi
n
g
.
In addition, please provide verification of your schedule.
Student
Name
T
r
a
i
n
i
n
g
S
ite
/
S
c
h
oo
l
N
a
m
e
Address and Phone
Name:
Address:
Phone: ( )
Beginning
Date
End
Date
Schedule
Name:
Address:
Phone: ( )
CHILD’S SCHOOL INFORMATION:
Child’s Name Name of School
S
c
h
oo
l
S
c
h
e
du
l
e
/
S
c
h
oo
l
T
r
a
c
k
Current Grade Level
CHILD CARE PROVIDER:
Child or Children’s Names
Provider Name
Address and Phone Number
Name:
Address:
Phone: ( )
Name:
Address:
Phone: ( )
YOUR RIGHTS
4
2151-WC(01-18)
Anyone who has been denied, terminated, or had benefits reduced will receive a notice and instructions for requesting a hearing if
you do not agree with the action taken. You can request a hearing by writing your local child care office, Division of Welfare and
Supportive Services (DWSS) district office or administration office. You can also request a hearing by signing and returning the
Notice of Appeal you receive. You must request a hearing within 90 days of the notice date or within 14 days if you want continued
benefits while your hearing is pending a decision.
If you request a hearing, you will be notified of the hearing date, time and location in writing ten (10) days prior to the scheduled
h
ea
r
i
n
g
.
Y
o
u
m
a
y
b
e
r
e
pr
ese
n
t
e
d
a
t
a
c
on
f
e
r
e
n
ce
/
h
ea
r
i
n
g
b
y
a
n
y
on
e
w
ho
m
y
o
u
h
ave
g
i
ve
n
w
r
i
tt
e
n
a
u
t
hor
i
z
a
t
i
on
.
Th
i
s
w
r
i
tt
e
n
a
u
t
hor
i
z
a
t
i
on
mu
s
t
b
e
g
i
ve
n
t
o
t
h
e
D
W
SS
o
ff
i
ce
be
f
or
e
t
h
e
c
on
f
e
r
e
n
ce
/
h
ea
r
i
n
g
.
P
l
ease
c
ont
ac
t
u
s
i
f
y
ou
ne
e
d
i
nfor
m
a
t
i
on on
l
e
g
a
l
services that may be available to you at no cost.
If you disagree with your hearing decision, you can appeal your case to your local District Court of the State of Nevada.
A
U
T
HO
R
IZ
A
TIO
N
/
R
E
S
PO
N
S
IB
IL
IT
Y
The Child Care and Development Program is funded by State and federal grants. Any information provided on this form can be
investigated. Criminal prosecution and other penalties may be applied to you and/or other adult members of your household
according to state and federal law. If you make a false or misleading statement, misrepresent, hide or withhold facts to get or keep
c
h
il
d
ca
r
e
a
ssi
s
t
a
n
ce
,
y
o
u
r b
e
n
e
f
i
t
s
m
a
y
b
e
r
e
d
u
ce
d
/
d
e
n
i
e
d
/
t
e
r
m
i
n
a
t
e
d
.
A
dd
i
t
i
on
a
ll
y
,
y
o
u
m
a
y
no
t
b
e
e
li
g
i
b
l
e
f
or
f
u
t
u
r
e
ass
i
s
t
a
n
ce
,
and you are responsible to pay back all monies, services and benefits for which you were not entitled. Information provided is
strictly confidential and is used only to determine eligibility for child care assistance.
By signing below, you authorize the Child Care and Development Program and/or the Division of Welfare and Supportive Services
t
o
m
ake
a
n
y
i
n
ves
t
i
g
a
t
i
on
c
on
ce
rn
i
n
g
y
ou or
ot
he
r
m
e
m
b
e
r
s
of
y
o
ur
hou
se
hol
d or
y
our
c
h
il
dr
e
n
’
s
l
e
g
a
l
/
p
u
t
a
t
i
ve
p
a
r
e
n
t
(
s
)
t
h
a
t
i
s
necessary to determine eligibility for child care assistance administered by the Child Care and Development Program.
By signing below, you authorize the release of information about your household members to the Child Care and Development
Program including, wage information, information made confidential by law or otherwise, and patient information privileged under
NRS 49.225 or any other provision of law or otherwise. You release the holder of such information from liability, if any, resulting
from disclosure of the required information. A reproduced copy of this authorization legally constitutes an original copy.
By signing below, you acknowledge that you understand the questions on this application and the penalty for hiding or giving false
information. In addition, you understand that if you make a false or misleading statement, hide or withhold facts to get or keep
child care assistance, your benefits may be reduced, denied, or terminated and you may be disqualified from program participation,
criminally prosecuted, or otherwise penalized according to state and federal law.
I
n
a
dd
i
t
i
on,
by
s
i
g
ning
b
e
l
o
w
,
y
ou
c
on
f
i
r
m
t
h
a
t
t
h
e
pro
v
i
d
er(s
)
li
s
t
e
d
a
bo
ve
r
e
f
l
ec
t
t
h
e
c
ho
i
ce
m
a
d
e
b
y
y
ou
,
t
h
e
p
a
r
e
n
t
/
ca
r
e
t
ake
r
,
a
nd
you agree to indemnify and hold harmless the State of Nevada, the Child Care and Development Program, their officers, agents,
board members and employees from all claims, litigation, costs, expenses and liabilities arising out of, or in any way connected with
the provider chosen by you.
I certify under penalty of perjury, my answers are true, correct and complete to the best of my knowledge and ability.
Signature or
Mark of Applicant (Parent/Guardian)
Date
S
i
g
n
a
tu
r
e
o
r
M
a
r
k
o
f
S
p
o
u
s
e
/
S
eco
nd
Parent/Guardian of Child(ren)
Date
5
2151-WC(01/18)
IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW,
WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY?
(Please check one)
YES NO
If you do not check either box, you will be considered to have decided not to register to vote at this time.
The NATIONAL VOTER REGISTRATION ACT provides you with the opportunity to register to vote at this location. If you
would like help in filling out a 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.
IMPORTANT NOTICE: Applying to register or declining to register to vote WILL NOT AFFECT the amount of assistance
you will be provided by this agency.
Signature Date
CONFIDENTIALITY: Whether you decide to register to vote or not, your decision will remain confidential.
IF YOU BELIEVE SOMEONE HAS INTERFERED with your right to register or to decline to register to vote, or your right to
choose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State,
Capitol Complex, Carson City, Nevada 89710.
6
2151-WC(01/18)
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DIVISION OF WELFARE AND SUPPORTIVE SERVICES Child Care (State of Nevada, Department of Information Technology)

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Completed 11 December 2021

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