Honolulu Community Action Program - Providing ...



Parent/Guardians Name : FORMTEXT ?????Child’s Name: FORMTEXT ?????Relevant Time Period: from: FORMTEXT ?????to: FORMTEXT ????? Documents Provided FORMCHECKBOX Child’s Birth Certificate, Hospital Certificate, Baptismal Certificate, or Passport FORMCHECKBOX Public Assistance: FORMTEXT ????? FORMCHECKBOX Supplemental Security Income FORMCHECKBOX Verification of Homelessness FORMCHECKBOX Verification of Foster Care FORMCHECKBOX Verification of Legal Guardianship/Power of Attorney FORMCHECKBOX Current Tax Forms: FORMTEXT ????? FORMCHECKBOX W2 FORMCHECKBOX Pay Stubs for FORMTEXT ????? Job 1: FORMTEXT ????? Month: FORMTEXT ????? Job 2: FORMTEXT ????? Month: FORMTEXT ????? Job 3: FORMTEXT ????? Month: FORMTEXT ????? Job 4: FORMTEXT ????? Month: FORMTEXT ????? FORMCHECKBOX Pay Stubs for FORMTEXT ????? Job 1: FORMTEXT ????? Month: FORMTEXT ????? Job 2: FORMTEXT ????? Month: FORMTEXT ????? Job 3: FORMTEXT ????? Month: FORMTEXT ????? Job 4: FORMTEXT ????? Month: FORMTEXT ????? FORMCHECKBOX LES (military income) Months: FORMTEXT ????? FORMCHECKBOX Self-Employment (net income, Schedule C, monthly ledger) FORMCHECKBOX Child Support Statement FORMCHECKBOX Social Security Income (Retirement, Disability, Survivor) FORMCHECKBOX Income Statement (Self Declaration, No Income, Employer’s Verification Justification) FORMCHECKBOX Medical/Dental Health Insurance FORMCHECKBOX WIC #: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????I attest the information I provided above is accurate information regarding my family's income and/or current situation used to determine my child’s eligibility. I further understand that intentionally providing misleading, inaccurate or untruthful information of a material nature could result in disenrollment from Head Start and serious legal consequences from the U.S. Federal Government.School Year: FORMTEXT ?????/ FORMTEXT ?????Parent/Guardian’s NameParent/Guardian’s SignatureDate ................
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