New Submission

Parent/Guardian First Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Parent/Guardian Last Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Do you currently have an open case with Child Care Services?*field type radio button
Do you currently have an open case with Child Care Services?yesno
Social Security Number (Input Numbers Only)field type single line
Input blocked. Maximum character limit of 4000 characters reached.
TWIST IDfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email Address*field type email
Child Care Services sends all communication through Email. It is VERY important to enter a valid email and check that email on a regular basis to avoid missing communication which could cause an interruption or delay in your services.
Name of person receiving self-employment income*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Give the month covered by this income statement (3 months required)*field type drop-down
Describe your self employment profession*field type multi line
CCS requires proof of self-employment, please attach DBA or other verifying certification.field type file upload
Drop files here
You have reached the maximum file limit: .
List your business income and expenses below. (IMPORTANT: Must attach copies of receipts, invoices, or other verifying documents.)
Expenses must be related to self-employment profession.

Each Income Source

	Date*field type date	Income (List each month separately)*field type single line	Amount*field type currency
Row 1×	Date*field type date	Income (List each month separately)*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Amount*field type currency $	×

Click Here to Add Additional Income Sources

Total Incomefield type currency
$
Proof of income received are required for CCS determination.*field type file upload
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You have reached the maximum file limit: .

Each Expense Source

	Date*field type date	Expenses (List each month separately)*field type single line	Amount*field type currency
Row 1×	Date*field type date	Expenses (List each month separately)*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Amount*field type currency $	×

Click Here to Add Additional Expense Sources

Total Expensesfield type currency
$
Proof of expenses are required for CCS determination. - Copies of receipts, invoices, or other verifying documents.*field type file upload
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You have reached the maximum file limit: .

This above information is true, correct, and complete to the best of my knowledge. I understand that giving false information could result in my being disqualified for fraud.
Signature*field type signature
Datefield type date
Date will be captured on form submission
By signing electronically, I agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

Workforce Solutions South Plains is an equal opportunity employer/programs. Auxiliary aids and services are available upon request to individuals with disabilities. Relay Texas: 711 (voice); 800-735-2989 (TDD); or Relay Texas Spanish 800-662-4954.

Sourcefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
LINKEntryIDfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
LinkTWISTIDfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
LinkFirstNamefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
LinkLastNamefield type single line
Input blocked. Maximum character limit of 4000 characters reached.

PARENT’S STATEMENT OF SELF-EMPLOYMENT INCOME

Each Income Source

Each Expense Source