Fillable Printable DHS 7470 from Oregon DHS Applications home

DHS 7470 from Oregon DHS Applications home

Page 1 of 5 DHS 7470 (03/13), recycle prior versions

Application for

Employment Related Day Care (ERDC) Program

You will need to give proof of your income. The following are examples.

Bring or send those that apply to you.

• Pay stubs or employer statements of gross pay

• Workers’ compensation check

• Latest award letter from Social Security or Veteran’s Administration

• Court order stating amount of child support or alimony

• Records of income from self-employment

• Last year’s tax statement, if self-employed

• Student Financial Aid Award letter

• Records for property and other income sources

1. Completethisapplicationandturnitintoyourlocalofce.

2. Give proof of eligibility.

3. Have an interview with a worker in person or by phone.

This application is for the Employment Related Day Care Program (ERDC). It is for

childcarebenetsonly.Familiesseekingcash,foodormedicalbenetsshouldnot

use this application.

To contact our ofce

Please read these instructions before lling out this application. Answer all questions. Do not

write in the shaded areas.

How do I prove eligibility

How do I apply for ERDC

Who should complete

this application

Self Sufﬁciency Programs

Ifyouhavequestionsorchangestoreport,contactourofce:

Name:____________________________________________________________

Address:___________________________________________________________

Phone:____________________________________________________________

If your child has a disability, you may qualify for a higher child care payment rate. Your child must have a disability

that requires extra care. To see if you qualify, you must complete and return a Special Need Child Care Rate Request

form (DHS 7486).

If your child is older than age 11, you may still qualify for child care help. Your child must meet certain requirements.

Talk to your worker to see if you qualify.

• You have the right to talk to your worker or a person in charge.

• You have the right to request a hearing if you disagree with the decision on

your application.

Applicant rights

Page 2 of 5 DHS 7470 (03/13), recycle prior versions

If you get ERDC, you must report the following changes within 10 days

of occurrence:

• Changes in child care providers

• Changes in employment status

• Changes in mailing address or residence

• When someone moves in or out

• Changes in the source of income or rate of pay

Tear off this page and keep it for your records

Client responsibilities

Our discrimination policy

The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not discriminate against

anyone. This means that DHS|OHA will help all who qualify and will not treat anyone differently because of age,

race, color, national origin, gender, religion, political beliefs

, disability or sexual orientation

YoumayleacomplaintifyoubelieveDHSorOHAtreatedyoudifferentlyforanyofthesereasons.

Toleacomplaintwiththestate,youcancalltheGovernor’sAdvocacyOfceat1-800-442-5238

(TTY711)orwritetotheirofceat:

Governor’sAdvocacyOfce

500 Summer Street NE, E17, Salem, OR 97301

Fax:503-378-6532

Email:[email protected].us

“Equal opportunity is the law!”

The United States Department of Agriculture (USDA) and the United States Health and Human Services (HHS) a

re equal opportunity providers and employers. Auxiliary aids and services are available upon request to individuals

with disabilities.

ToleacomplaintwithUSDAandHHS,pleasereadthe“Client Discrimination Complaint Information”

form(DHS9001).Youcanndthisforminthe“Information and Referral Packet” (DHS 6609).

SNAP clients are protected against political belief discrimination.

Sexual orientation is protected by the State of Oregon, but not federal laws.

A client assigned to the Simplied Reporting System must report changes by the 10th of the following month after the

change happens. Your worker will explain these changes to you.

Tocontinuegettingbenets,youmustreapplybycompletingtheEmployment Related Day Care (ERDC)

Re-Application and Supplemental Nutrition Assistance Program (SNAP) Application form (DHS 7476) or

Application for Services (MSC 0415F).

You must help the Department of Human Services (DHS) if your case is chosen for review.

You must agree to use a child care provider that meets DHS listing requirements.

Page 3 of 5 DHS 7470 (03/13), recycle prior versions

Application for

Employment Related Day Care (ERDC) Program

Are your children’s immunization (shot) records up-to-date?

Yes

If not, contact your doctor or local health department for more information. You must agree to meet state

immunizationguidelinestogetchildcarebenets.

*Racial heritage - We ask for this information to help us follow Federal Civil Rights laws. Title VI of the

Civil Rights Act of 1964 allows us to do this. You can choose not to give this information. It will not affect your

eligibility for services. (Select one or more for each person below) W - White A - Asian

I - American Indian/Alaska Native B - Black or african American P-PacicIslander/NativeHawaiian

** Ethnicity - H - Hispanic/Latino N - Not Hispanic/Latino

*** Providing a Social Security number (SSN) is voluntary when applying for ERDC.

List all people living with you, even if you are not applying for them. If you need more room,

attach another sheet.

Agency use only

Program: Agency:

Casenumber: WorkerID:

Casename:

FILE

Name

(last, rst, M.I.)

Relationship

Social

Security

number***

Date of

birth

Sex

M = Male

F = Female

Y = Yes or N = No

Racial

Heritage *

(circle)

Ethnicity**

Child

needs

care

Needs extra

care for

disability

U. S.

citizen

Self