Expectant Mom s Program
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1 Bergen County Community Action Partnership, Inc. Child Care Services Head Start/Early Head Start Administrative Offices 241 Moore Street, Hackensack, NJ Phone: (201) ext Fax: (201) Expectant Mom s Program
2 Bergen County Community Action Partnership, Inc. Child Care Services Head Start/Early Head Start Administrative Offices 241 Moore Street, Hackensack, NJ Phone: (201) ext Fax: (201) Enclosed is the application for Bergen County Community Action Partnership, Inc., Early Head Start Expectant Mom s Program. Please complete all sections. You must personally bring the completed application and required documentation to our Administrative Offices located at: 263 Lafayette Ave. Cliffside Park, NJ Applications are accepted: Monday through Thursday 9:30 A.M until 11:30 A..M. and 1:30 P.M. until 3:30 P.M. Required Original Documentation 1. The completed application. 2. Income verification for household: Last year s Income Tax Return, Form Two (2) current consecutive pay stubs for bi-weekly or bi-monthly payroll; Four (4) current consecutive pay stubs for weekly payroll. If you are receiving any form of public assistance, we will need a letter from Social Services stating what and how much you are receiving. Verification of any child support payments you may be receiving. Divorce decree (if applicable). Notarized letter (on company letterhead) from employer stating your salary, hours, as well as your year-to-date income (if applicable). Social Security card(s) for all members in the family (Optional). 3. Proof of residency that shows your current address. Original Lease or Deed. A current electric or gas bill. A current telephone bill. 4. Medical Insurance Card. ************************************** Please call us at the telephone number shown above with questions. Thank you.
3 Bergen County Community Action Partnership, Inc. Child Care Services Head Start/Early Head Start Administrative Offices 241 Moore Street, Hackensack, NJ Phone: (201) ext Fax: (201) Adjunto encontrará la aplicación para Early Head Start Expectant Mom s Program del Bergen County Community Action Partnership, Inc. Por favor llene todas las secciones. Usted debe traer la aplicación con todos los documentos originales a nuestra Oficina Administrativa localizada en: 263 Lafayette Ave. Cliffside Park, NJ Aplicaciones son aceptadas: Lunes a Jueves 9:30 A.M hasta 11:30 A.M. y 1:30 P.M. hasta 3:30 P.M. Documentación Original Requerida 1. Aplicación completamente llenada. 2. Prueba de ingreso de la familia: Copia de los Impuestos del año anterior (Income Tax Return, Form 1040). Dos (2) talonarios de pago consecutivo si le pagan quincenal o si cobra dos veces al mes. Cuatro talonarios de pago consecutivo si le pagan semanal. Si usted recibe asistencia del gobierno (TANF, SSI etc.), necesitaremos la carta de Servicios Sociales indicando cuanto usted esta recibiendo. Verificación de manutención monetaria para niños (child support). Decreto de Divorcio (Si es Aplicable). Carta notariada de verificación de empleo del patrón o negocio con el membrete comercial de la compañía. Tarjetas de Seguro Social para todos los miembros de la familia (Opcional). 3. Prueba de residencia, que muestre su dirección actual. Contrato de vivienda (léase) o Deed. Una factura de gas ó servicio de electricidad Una factura de teléfono actual. 4. Tarjeta de Seguro Medico. **************************************** Por favor llame al teléfono proporcionado arriba si usted tiene alguna pregunta. Gracias.
4 Expectant Mom Name Last (Apellido ) Part I: Application Social Security # Date of Birth (Fecha de Nacimiento) Month / Day / Year / / Age Gender (# Seguro Social) (Mes / Día /Año) (Edad) (Sexo) Highest Level of Education: Due Date (Fecha de el Parto) Month / Day / Year / / Occupational Status (Trabajo) Address (Domicilio) Street Address ( Número y Calle) Apt. Fl. (Piso) City, State, & Zip Code (Cuidad, Estado & Código Postal) (Teléfono del Hogar /Código de área) Race / Ethnicity (Raza / Grupo Ětnico) Speaks fluent English? (Habla inglés?) Native Language (Lenguaje Natal) Family country of origin (País natal de la familia) Spouse Last (Apellido ) Social Security # Date of Birth (Fecha de Nacimiento) Month / Day / Year / / Age Gender (# Seguro Social) (Mes / Día /Año) (Edad) (Sexo) Highest Level of Education: (Nivel mas alto de educación) Occupational Status (Trabajo) Cell Phone incl. Area Code (Celular /Código de área) Race / Ethnicity Speaks fluent English? Native Language Family country of origin (Raza / Grupo Ětnico) (Habla inglés?) (Lenguaje Natal) (País natal de la familia) Children in household (Niños residiendo en el hogar) Full Name (Nombre Completo) Social Security # (# Seguro Social) Date of Birth (Fecha de Nacimiento) Gender (Sexo) Age (Edad) Grade (Grado) School (Escuela) * If you need to add additional people please do so on another blank sheet and attach to this form* (*Sí necesita añadir mas personas por favor hágalo en una hoja separada y añada la hoja a este formulario*)
5 Cont. Part I: Application Name Last (Apellido ) Types of services family receives (Tipo de services que la familia recibe). Supplemental security income/ SSI (Ingreso suplementario de seguridad) Child Support or Alimony (Pagos de manutención para niños y divorciantes) Unemployment insurance (Seguro de desempleo) Public housing assistance (Subsidio de vivienda pública) Home energy assistance (Subsidio del programa de energia) WIC Public assistance/ TANF (Asistencia pública/ bienestar) Case # Food stamps (Cupones/ Estampillas de alimento) Case # Foster care/adoption subsidy Subsidio para el cuidado de crianza o la adopción de niños Case # Medical financial assistance/ Medicaid /Medicare (Subsidio Médico) Insurance Name (Nombre del seguro Médico): I.D. number (Numero de identificación): Private Medical Insurance/ (Seguro Médico Privado) Family Currently Has Means of Transportation (La Familia Actualmente dispone de Medio de Transporte): Private vehicle (Vehículo Propio) Friend s or relative s vehicle Vehículo de un amigo o familiar Public transportation Trasporte público Housing Payment Arrangement (Forma de Pago de la Vivienda): Own (Propia) Exchange services for housing Ofrece servicios a cambio de vivienda Rent (Rentada) Receive subsidized housing Recibe subsidio de vivienda Make no payment for housing No hacen pagos por la vivienda I certify that all of the information contained in this application is true under the penalties as prescribed by the laws of the State of New Jersey and the United States Government. (Certifico que la información contenida en esta aplicación es correcta bajo las penalidades establecidas en las leyes del Estado de NJ y los Edtados Unidos) Signature (Firma ) Date (Fecha) AGENCY USE ONLY I certify that the information given to me on this application has been reviewed and when possible supported by documentation. Referral Source: Staff Signature: Print Staff name: Date: / / Age Verification: Birth Certificate Passport: IMM: Source of Income: Tax Return W2 Pay Stub Notarized letter Employer Income Declaration Unemployment Allotment Letter: Other Annual Income Verification: $ Proof of residence Provided: # of Adults # of Child(ren) CSST Returned Medical & Dental
6 Part II: Emergency Form Name Last (Apellido ) Address (Domicilio) Street Address ( Número y Calle) Apt. Fl. (Piso) City, State, & Zip Code (Cuidad, Estado & Código Postal) (Teléfono del Hogar /Código de área) Physician (Medico) Physician's Phone (Teléfono del Pediatra) Allergies (Alergias) Medications (Medicamentos) Please list at least 3 people to contact in case of an emergency (Por favor indique por lo menos 3 personas que podamos llamaren caso de una emergencia) 1 2 Name (Nombre) Relationship (Parentesco) (Tel. del Hogal /Código de área) Area Code & Cell phone (Cellular con Código de área) Area Code & Business Phone (Num. del Trabajo con Código de área) 3 4 Name (Nombre) Relationship (Parentesco) (Tel. del Hogal /Código de área) Area Code & Cell phone (Cellular con Código de área) Area Code & Business Phone (Num. del Trabajo con Código de área) Signature (Firma) Date (Fecha)
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