You MUST complete the Jobs and Family Service form (1^st form of this packet)

All other sections of this packet MUST be electronically signed and submitted. You MUST sign, even if the form does not apply to you.

Please provide addresses, phone and Fax #’s for Employers and Child Care Providers if applicable.

Following the submission of these forms you MUST submit any and all of the following that may apply:

• Verification of income
• 4-6 current pay stubs for all employed household members
• Receipts of amount paid for child care
• Notarized No income statement for all adults with ZERO income

These verifications are still requested, however some employers and/or childcare providers will not respond to our request.

NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or agency of the United Sates as to any matter within its jurisdiction.

I agree that the above typed signature will be the electronic representation of my signature for all purposes-just the same as a pen and paper signature.