Spanish - Early Childhood Programs

EARLY CHILDHOOD SCHOOL READINESS PROGRAMS
Solicitud de cambio de Estatus
Fecha: _______________________
Yo, ________________________________________, SS# _______________________, solicito que el cambio
de estatus sea efectivo a partir de: _________________________ (especificar fecha)
El cambio aplica al niño (s) listado debajo.
Lista de niño(s):
SS/ID#
Nombre del niño
1.
2.
3.
El CAMBIO DE:
Ejemplo de Formas o Documentación que Adjuntar:


Estado Civil
Empleo
Formulario de Información del Cliente /Licencia de Matrimonio/Decreto de Divorcio
Formulario de Verificación de Empleo /Carta del Empleador/ Talonarios de Pago o Recibos

Pérdida/Interrupción de empleo

Ingreso



Horario de Empleo
Escuela
Habitantes en el Hogar

Manutención de Niños






Cambio de Dirección
Estampillas de Alimentos
Asistencia de Vivienda
Seguro Social (SSI/SSDI/SSB)
Añadir un niño
Otra Razón
Formulario de Pérdidad de Empleo / Una Carta del Empleador
Formulario de Verificación de Pago / Una Carta del Empleador/ Talonarios de Pago
Formulario de Verificación de Horario de Empleo / Una Carta del Empleador
Formulario de Verificación de Estudio / Una Carta de la Escuela/ Calendario de Clases
Formulario de Información del Cliente
Formulario de Verificación de Manutención de Niños / Copia impresa del historial de pagos
via la pagina web del Dept. de CSE al: www.myfloridacounty.com
Formulario de Solicitud de Cambio de Dirección / Verificacion de la Nueva Dirección
Verificación por parte de DCF/Carta de Autorización
Verificación de Asistencia de Vivienda
Una carta oficial del Departamento de Seguro Social
Formulario para Añadir un niño (s) / Verificación de Edad y Ciudadanía o Estatus Legal
Nota: Si este es un nuevo empleo, la sección sobre perdida de empleo es también necesaria.
**Nota – El Padre/Guardian debe llenar un nuevo formulario SR-100* cuando el cambio que esta reportando represente
cambios de ingresos, tamaño del nucleo familiar, fuente de ingresos.
*Todos los formulario pueden ser encontrados en la siguiente pagina web: www.sdhc.k12.fl.us/doc/list/earlychildhood/documents-forms/153-711. (Por favor provea la documentación pertinente para verificar el cambio.)
Explique completamente el cambio que está solicitando____________________________________________
_______________________________________________________________________________________
Comprendo que firmando esta petición yo autorizo al Programa de School Readiness a efectuar el cambio que yo por la presente he
solicitado.
____________________________________________
__________________________________________
La firma de Padre/Guardián
Fecha
Office use only:
Date form received: ___________________ Received by: ____________________________________
Form completed? □Yes □No If no, reason: ________________________________________________________ (contacted client on status)
Brandon
9325 Bay Plaza, Suite 210
Tampa, FL 33619
PH (813) 740-4713
Fax (813) 740-4722
Status Change Fax (813) 739-6042
North Tampa
9309 N. Florida Ave., Suite 104
Tampa, FL 33612
PH (813) 915-3200
Fax (813) 915-3239
RBM & Status Change Fax (813) 915-3236
Administrative office @ Net Park
5701 E. Hillsborough Ave., Suite 2301
Tampa, FL 33610
PH (813) 744-8941 ext. 254
Fax (813) 744-6753
Request to Change Status – Spanish 9/11/08 – Revised 10/7/16
The Office of Early Learning
INCOME WORKSHEET for Eligibility and Parent Copayments
SECTION I. EARNED INCOME
Complete the following information about each adult family member in the household who is employed or participating in education. Provide proof of all
income and/or participation in education/training declared on this form. Provide proof of all payments received with this form. I f payments are received:
Weekly: must provide last six (6), Bi-Weekly- must provide last three (3) Semi-Monthly- must provide last four (4), or Monthly- must provide last two (2).
Check One:
□ Single Parent Household
□ Two‐Parent Household
Parent(s) with whom the child resides (includes parents by marriage or adoption)
Name of Person
Who Works
Name, Address and
Telephone Number of
Employer(s)
Occupation
Parent 1:
Gross Earned Income (before taxes)
Frequency
Amount
□ Hourly
□ Weekly
□ Bi‐weekly*
□ Semi‐monthly*
□ Monthly
□ Annual
Total Gross Annual Earned Income:
$
$
$
$
$
$
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
$
Total Hours
Worked Per
Week:
Total
Classroom/
Lab Hours
Per Week:
Parent 2:
$
Monday
□ Hourly
$
Tuesday
□ Weekly
$
Wednesday
□ Bi‐weekly*
Thursday
□ Semi‐monthly* $
$
Friday
□ Monthly
$
Saturday
□ Annual
Sunday
Total Gross Annual Earned Income:
$
Total Hours
Worked Per
Week:
Name, Address and Telephone Number of School:
Total
□ Education
□Semester
Classroom/
□Quarter
Lab Hours
□Other
Per
Week:
Additional adult family members in the home who are employed (includes children over 18 who are not enrolled as full‐time students in
secondary schools** or their equivalent and related adults who are supported by the family).
□ Education
Additional
Household
Member 1:
Additional
Household
Member 2:
Name, Address and Telephone Number of School:
Weekly Work Schedule
Day of Week
From
To
□Semester
□Quarter
□Other
□ Hourly
□Weekly
□Bi‐weekly*
□Semi‐monthly
□Monthly
□Annual
$
$
$
$
$
$
Total Gross Annual Earned Income:
$
□Hourly
□Weekly
□Bi‐weekly*
□Semi‐monthly
□Monthly
□Annual
$
$
$
$
$
$
Total Gross Annual Earned Income:
$
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total Hours
Worked Per Week:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total Hours
Worked Per Week:
* Biweekly means paid every other week; Semi‐monthly means paid twice per month
** A school that is intermediate in level between elementary school and college includes middle/high, vocational/technical, and college‐prep schools
SR #100
SECTION II. UNEARNED INCOME
If any family member receives any of the following type of unearned income (or benefits), check the type of benefits received. Enter the case or account
number, the amount received, and the name of the family member receiving the payment. Provide proof of all payments received with this form. I f payments are
received: Weekly: must provide last six (6), Bi-Weekly- must provide last three (3) Semi-Monthly- must provide last four (4), or Monthly- must provide last two (2).
Unearned
Income Type
Adoption Subsidy Payments
Alimony received
Case/Account
Number
Monthly
Amount Received
$
$
Annual
Amount Received
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Name of Family Member
Receiving Payment
Cash (Income/money received from non‐ family
members residing in the household)
Child Care benefits
Child Support received (if multiple
payments, list each separately):
1.
2.
3.
Economic Stimulus
Food Stamps benefits
Foster Care payments
Housing assistance from HUD issued directly
to a landlord (and utilities)
Housing assistance from HUD issued directly to
member of the household (and utilities)
Military Food Assistance
Military FSSA housing assistance
Pension benefits
Relative Caregiver benefits
Retirement benefits (SSA)
Social Security Benefits
SSA Survivor Benefits for child
Social Security Disability income for client
Supplemental Security Income for client(SSI)
Supplemental Security Income for child (SSIC)
TANF cash assistance
Unemployment Compensation benefits
Veteran’s benefits
Worker’s Compensation benefits
Other income (list):
1.
2.
$
Total Annual Unearned Income
SECTION III. DEDUCTIONS
If any family member makes any of the following type of payments, check the type of payment made. Enter the case or account number, the amount paid,
the name of the family member making the payment, and the date of the last payment. The caseworker will deduct or exclude these payment types from
total family income upon receipt of proof of payment. If payments are paid out: Weekly: must provide last six (6), Bi-Weekly- must provide last three (3) SemiMonthly- must provide last four (4), or Monthly- must provide last two (2).
Authorized
Deductions
Alimony paid pursuant to a court
order
Child support payments paid
pursuant to a court order
Case/Account
Number
Monthly
Amount Paid
Annual
Amount Paid
$
$
$
$
Name of Family Member
Making Payment
Date of Last
Payment
$
Total Annual Authorized Deductions
I hereby certify that the information given in this worksheet is true and complete to the best of my knowledge. I understand that if I knowingly give
wrong information, I may be liable for prosecution under state law and that School Readiness services may be terminated. I also understand that if
any changes occur to the information on this worksheet, I will notify the coalition of those changes within ten (10) calendar days.
Signature of Parent/Guardian
Date
Signature of Eligibility Determiner
OFFICIAL USE ONLY – School Readiness staff to complete this section.
Total Annual Gross Income
Household Size (Include parent(s),
(Earned Income + Unearned Income –
children, and related adults in the home
Deductions)
who are supported by the family)
$
$
Date
Required Family Contribution/Parent
Copayment
$
SR #100