OEC Application 07/2024 Page 1 of 4
Office of Early Childhood School Readiness Application
The Early Childhood School Readiness Program is administered by the Office of Early Childhood (OEC), to include Arkansas Better
Chance (ABC) and Child Care Development Fund (CCDF). The purpose of the program is to increase the availability, affordability,
and quality of childcare services for families in the state of Arkansas. Families who are eligible for assistance receive free or
reduced childcare at approved state licensed providers (pending the availability of funds).
For information regarding Child Care services, Rights & Responsibilities and income guidelines, visit our website at:
https://dese.ade.arkansas.gov/
For county resource information visit: https://humanservices.arkansas.gov/arworksresource/
IN ORDER TO PROCESS YOUR APPLICATION FOR OFFICE OF EARLY CHILDHOOD
For CCDF: Submit application and required documentation to oec.familysupport@ade.arkansas.gov
For ABC: Submit application and required documentation to a selected ABC Provider
APPLICATION:
Completed application: All sections must be completed, and the application must be signed and dated.
(incomplete applications will be returned or denied)
Declaration of asset question answered.
DOCUMENTATION REQUIREMENTS:
Photo ID for all adults in the eligibility group: driver’s license, military, school, state issued, or passport
Photo ID for authorized representative (if applicable): driver’s license, military, school, state issued, or passport
Birth certificate for each child that services are requested
Proof of citizenship for each child that services are requested
Proof of Applicant’s Residence (physical address): may include but not limited to; lease contract, rent receipt,
mortgage contract, bills, mail, state, or federal issued ID, check stubs, statement, or state systems verification.
Valid email address
Social security number verification for each household member (required for each child services are requested).
Immunization record/catch up schedule
Well child screening/Physical
Guardianship Documentation
INCOME VERIFICATION (must be provided for all household members within the family eligibility group):
Earned income: Supporting documents must include copies of consecutive check stubs for the last 30 days if applicable.
-If paid weekly, the last four (4) consecutive check stubs are required
-If paid bi-weekly (every two weeks), the last two (2) consecutive check stubs are required
-If paid semi-monthly (twice per month), the last two (2) consecutive check stubs are required
-If paid monthly, one (1) check stub for the last month is required, or
▪ OEC Verification of Employment (VOE) form- completed by employer, or
DCO-97 Verification of Earnings form- completed by employer,
▪ Contract Agreement – A copy of the current contract between employee and employer
Self-employment earned income: Documents to verify may include but are not limited to,
▪ Last year’s 1040 Tax Return with applicable schedule form (profit or loss from business); OR
▪ DCC-575 Self-Employment Declaration form for last 30 days if applicable
.
(Only if self-employed for less than 1 year)
UNEARNED INCOME: Supporting documents must include verification for last 30 days (if applicable)
Supplemental Security Income (SSI) Social Security payments
Workers Compensation Unemployment
Alimony received for the last three (3) months Pensions, interest, and annuities
Contributions Notarized statement of no earned income
EDUCATION/JOB SKILLS TRAINING:
Class Schedule: verification of enrollment, or written statement from advisor or institution on official letterhead
Job Skills training: verification of enrollment, or written statement from advisor or institution on official letterhead
GED/Adult Education: verification of enrollment, or written statement from advisor or institution on official letterhead
OTHER:
Child Care Arrangement Verification
OEC Application 07/2024 Page 2 of 4
Office of Early Childhood School Readiness Application
All applicants must be eighteen (18) years and over or an emancipated minor. All applicants must have physical custody of the
child(ren) for whom services are requested. If applying for Teen Parent, please enter Teen Parent’s information below.
REQUIRED INFORMATION NEEDED FOR ALL PROGRAMS.
Parent or Guardian/Teen parent Information:
Social Security # (Optional)
First Name (applicant) MI Last Name
Date of Birth
Gender:
☐ Male
☐ Female
Marital Status:
☐ Single ☐ Married ☐ Divorced
☐ Separated ☐ Widowed
Race (see codes):
Ethnicity: ☐ Hispanic or Latino
☐ Not Hispanic or Latino
Primary Language:
Highest Level of Education or
Training Completed:
Military Status (see codes):
# of Parents in home:
# in Family:
# of Household members:
Do you have household assets above $1,000,000? ☐Yes ☐No
Race Codes: A = Asian American B = Black/African American H = Hawaiian/Pacific
Islander I = American Indian or Alaskan Native W = White/Caucasian O = Other
Military Status Codes: (Adults Only): N/A = No AD = Active Duty
NGMR = National Guard/Military Reserve VUSM=Veteran of United States Military
Mailing Address
City/State
Zip
County
Home Phone/Cell:
Physical Address (if not the same)
City/State
Zip
County
Message Phone:
Current/Valid Email Address(required)
Second Parent or Guardian
Social Security # (Optional)
First Name MI Last Name
Date of Birth
Gender:
☐ Male
☐ Female
Marital Status:
☐ Single ☐ Married ☐ Divorced
☐ Separated ☐ Widowed
Race (see codes):
Ethnicity: ☐ Hispanic or Latino
☐ Not Hispanic or Latino
Primary Language:
Highest Level of Education or
Training Completed:
Military Status (see codes):
Mailing Address
City/State
Zip
County
Home Phone/Cell:
Physical Address (if not the same)
City/State
Zip
County
Message Phone:
Have you ever received TEA or ESS? ☐ Yes ☐ No
Have the child(ren) transitioned from foster care? ☐ Yes ☐ No
Do you have an open protective service case? ☐ Yes ☐ No
Are you a Guardian or Custodian with physical custody? ☐ Yes ☐ No
Do you receive SNAP Benefits? ☐ Yes ☐ No
Are you currently receiving WIC? ☐ Yes ☐ No
Is any adult in household Disabled? ☐ Yes ☐ No
Current Housing: ☐Own ☐Rent ☐Homeless ☐Other
Current Housing Date:
Has your family moved in the past 24 months? ☐ Yes ☐ No
Check if applicable: ☐ Teen parent resides in the household.
☐ Teen parent is attending high school or GED program.
☐ Lacks regular, fixed, or adequate nighttime residence
☐ Shares housing due to economic hardship
☐ Lives in a shelter, hotel, or motel
☐ Lives in a place not designed for sleeping (cars, parks, etc.)
HOUSEHOLD INFORMATION: * A family’s eligibility group is made up of one (1) or more adults and child(ren), who may or may not be, related by
blood or law and residing in the same house when at least one of the adults has physical custody of the child(ren) for whom application is made. In
households where adults other than spouses or parents of the child(ren) reside together, each may be considered a separate eligibility group. If
requesting services each eligibility group must complete a separate application. List all information for household members included in the eligibility
group.
Social Security #
First Name MI Last Name
Date of
Birth:
Gender
Citizen/Legal
Resident
Relationship to
applicant:
Services
Needed?
Race
(see codes)
Military Status
Adults only
(see codes)
☐ Male
☐ Female
☐ Yes
☐ No
☐ Yes
☐ No
☐ Male
☐ Female
☐ Yes
☐ No
☐ Yes
☐ No
☐ Male
☐ Female
☐ Yes
☐ No
☐ Yes
☐ No
☐ Male
☐ Female
☐ Yes
☐ No
☐ Yes
☐ No
☐ Male
☐ Female
☐ Yes
☐ No
☐ Yes
☐ No
☐ Male
☐ Female
☐ Yes
☐ No
☐ Yes
☐ No
OEC Application 07/2024 Page 3 of 4
EMPLOYMENT INFORMATION:
Name:
Employer:
Are you currently employed at a childcare facility who is a CCDF program participant? ☐Yes ☐No
Does your position with the program service birth to 5? ☐Yes ☐No
List work schedule below (List actual start/end times for each day)
Working Status: ☐Full Time ☐Part Time ☐Temporary ☐Seasonal
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Start Date:
Average Weekly Hours:
Estimated Daily Travel Time:
Name:
Employer:
Are you currently employed at a childcare facility who is a CCDF program participant? ☐Yes ☐No
Does your position with the program service birth to 5? ☐Yes ☐No
List work schedule below (List actual start/end times for each day)
Working Status: ☐Full Time ☐Part Time ☐Temporary ☐Seasonal
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Start Date:
Average Weekly Hours:
Estimated Daily Travel Time:
SCHOOL INFORMATION:
Name:
School:
☐ Currently aending GED program ☐ Currently aending high school ☐ Currently aending Higher Educaon or Job Skills Training Program
Start Date: End Date:
Hours Enrolled:
Student Status: ☐full me ☐part me
Major or course of study:
List school schedule below (List actual start/end mes for each day)
Esmated Daily Travel Time:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Name:
School:
☐ Currently aending GED program ☐ Currently aending high school ☐ Currently aending Higher Educaon or Job Skills Training Program
Start Date: End Date:
Hours Enrolled:
Student Status: ☐full me ☐part me
Major or course of study:
List school schedule below (List actual start/end mes for each day)
Esmated Daily Travel Time:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
HOUSEHOLD INCOME: Proof of ALL household income must be provided. List how oen received; Weekly, Bi-Weekly, Twice Monthly, Monthly
Name of person(s) receiving:
Gross Wages
SSI SSA
Commission Bonus
Other: (Explain)
Amount
How Oen
Amount
How Oen
Amount
How Oen
Amount
How Oen
Name of person receiving:
Gross Wages
SSI SSA
Commission Bonus
Other: (Explain)
Amount
How Oen
Amount
How Oen
Amount
How Oen
Amount
How Oen
OEC Application 07/2024 Page 4 of 4
INFORMATION FOR CHILD(REN) SERVICES ARE REQUESTED
Child’s Name
List any medical or
developmental disabilies
Name of Child care
Parcipant selected
List days and hours of care
needed for the child
Child aends ABC, Head
Start or Federal Pre-K
School child
currently aends
☐ Yes
☐ No
Medical Insurance
ARKids #
Does child have any special dietary needs? ☐ Yes ☐ No
List any allergies (food, insects, etc.):
Has child aended a state-funded Pre-K (ABC) program? ☐ Yes ☐ No
If so, where?
Will child be concurrently enrolled in an ABC center and HIPPY or PAT program? ☐ Yes ☐ No
If so, which HIPPY or PAT Program?
Does child receive any special educaon services? ☐ Yes ☐ No
Child’s Name
List any medical or
developmental disabilies
Name of Child care
Parcipant selected
List days and hours of care
needed for the child
Child aends ABC, Head
Start or Federal Pre-K
School child
currently aends
☐ Yes
☐ No
Medical Insurance
ARKids #
Does child have any special dietary needs? ☐ Yes ☐ No
List any allergies (food, insects, etc.):
Has child aended a state-funded Pre-K (ABC) program? ☐ Yes ☐ No
If so, where?
Will child be concurrently enrolled in an ABC center and HIPPY or PAT program? ☐ Yes ☐ No
If so, which HIPPY or PAT Program?
Does child receive any special educaon services? ☐ Yes ☐ No
Child’s Name
List any medical or
developmental disabilies
Name of Child care
Parcipant selected
List days and hours of care
needed for the child
Child aends ABC, Head
Start or Federal Pre-K
School child
currently aends
☐ Yes
☐ No
Medical Insurance
ARKids #
Does child have any special dietary needs? ☐ Yes ☐ No
List any allergies (food, insects, etc.):
Has child aended a state-funded Pre-K (ABC) program? ☐ Yes ☐ No
If so, where?
Will child be concurrently enrolled in an ABC center and HIPPY or PAT program? ☐ Yes ☐ No
If so, which HIPPY or PAT Program?
Does child receive any special educaon services? ☐ Yes ☐ No
Emergency Contact if parent/guardian cannot be reached:
Name:
Relationship:
Phone:
Address:
City:
State:
Zip:
Physician Name:
Phone:
Address:
City:
State:
Zip:
Consent for Emergency Medical Care:
I ______________________________________ ___________________________ of _____________________________________
Parent/Guardian’s Name Relationship Child Name
Do hereby request and give consent to the Director/Caregiver of the Child Care Facility, or their duly appointed representative, for said child to receive such medical or
surgical aid as may be deemed necessarily expedient by a duly licensed or recognized physician or surgeon in case of an emergency when parents cannot be reached.
Consent is also given for the Director/Caregiver or their duly appointed representative, to transport said child for emergency medical treatment, if parent(s) cannot be
reached.
_ _____________________________________________________ _ ______________________
Parent/Guardian Signature Date
Authorized Representative (If applicable): If you want to choose someone to represent you, please complete the following information. If you name an authorized
representative, this person will be able to talk to the case manager on your behalf.
(Photo ID required for authorized representative)
***CCDF Program Participant (child care provider) CANNOT be listed as authorized representative***
Name of Authorized Representative:
Home or Cell Phone #
*Applicant Certification:
I certify under penalty of perjury and fraud that all information I have supplied is true and correct. I understand that giving false information or withholding information
may result in denial, termination, or disqualification of services or criminal prosecution, and the repayment of financial assistance made on my behalf. I authorize OEC to
collect information from other sources to determine my eligibility for services. I authorize any source OEC deems necessary to determine eligibility to release
information concerning me. I certify that I have read and understand my Rights and Responsibilities, (available on the website).
Applicant Signature: _________________________ Applicant Printed Name: ___________________________ Date: __________
Teen Parent Signature: ________________________ Teen Parent Printed Name: ________________________ Date: __________
Official use only:
Program applying for? ☐Low Income ☐ESS ☐ABC ☐EHS ☐Federal Pre-K ☐ABC/ITS ☐ABC Summer ☐Other
