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Box for Office Use Only Provides space for the worker to record LDSS and case specific information. Forms submitted to the LDSS must be date stamped.

Section 1 The applicant must provide their contact and demographic information.

The applicant must provide information regarding receipt of prior benefits or services.

Section 2 The applicant must provide general information about all members of their household.

Section 3 The applicant must provide general information about any parent not living in the home.

Section 4 The applicant must provide information on the child(ren) for whom assistance is being requested.

Section 5 The applicant must provide employment or education/training information.

Section 6 The applicant must certify that family assets/resources do not exceed $1M.

The applicant must provide the income sources and the dollar amounts for all household members.

Section 7 Outlines the applicant’s responsibilities and change reporting requirements as well as the penalties associated with an intentional program violation.

Section 8 Consent to exchange information. Captures the applicant’s consent to share case information with other state agencies to provide efficient and coordinated services as needed.

Section 9 Acknowledgement of applicant’s responsibilities. Provides guidance for the worker and the applicant to discuss the application process, the information provided by the applicant and the responsibilities of the worker and the applicant. Provides space for the applicant and the worker to sign indicating that all required information has been submitted or requested and that the applicant understands and agrees to their requirements and responsibilities.

Provider Information Captures the name, address, and phone number of the Child Care Provider (if selected).