Forms

ELRC Region 5 is providing fillable PDF forms for families. These forms can be downloaded, filled out digitally, and sent back to the ELRC Region 5. NOTE: You must download the form prior to filling it out.

For additional questions, please contact ELRC Region 5 at 412.350.3577 or email us at elrc5@alleghenycounty.us.

Low-Income Forms

• Child Care Works (CCW) application

  • Español

• Authorization for Release of Information    

  • Español

• HIPPA Notice Signature Page

• Employment Verification

  • Español

• Self Employment Verification

  • Español

• Self Employment Schedule of Care

• Child Disability Verification

• Anticipated Self-Employment Income and Schedule

• Cash Verification

• Self Declaration Form

• Rights and Responsibilities Form- Low-Income/Head-Start

• Medical Assessment Form

• Homeless Verification

• Class/Training Schedule Verification

• Education Schedule Verification

• Parent/Caretaker and Related Provider Attestation

• Continuity of Care Application

Former Temporary Assistance for Needy Families (TANF) Forms

• FT Self-Certification Form

• Medical Assessment Form

• Homeless Verification

• Class/Training Schedule Verification

• Education Schedule Verification

• Authorization for Release of Information    

  • Español

• HIPPA Notice Signature Page

• Employment Verification

  • Español

• Self Employment Verification

  • Español

• Self Employment Schedule of Care

• Child Disability Verification

• Anticipated Self-Employment Income and Schedule

• Cash Verification

• Self Declaration Form

• Rights and Responsibilities Form- Low-Income/Head-Start/Former TANF

  • Español

• Parent/Caretaker and Related Provider Attestation

TANF Forms

• TANF/FS Self-Certification Form

  • Español

• Authorization for Release of Information    

  • Español

• HIPPA Notice Signature Page

• Employment Verification

  • Español

• Self Employment Verification

  • Español

• Self Employment Schedule of Care

• Child Disability Verification

• Anticipated Self-Employment Income and Schedule

• Self Declaration Form

• Education Schedule Verification

• Medical Assessment Form

• Class/Training Schedule Verification

Redeterminations

• Employment Verification

  • Español

• Self Employment Verification

  • Español

• Anticipated Self-Employment Income and Schedule

• Cash Verification

• Self Declaration Form

• Self Employment Schedule of Care

• Medical Assessment Form

• Homeless Verification

• Class/Training Schedule Verification

• Education Schedule Verification

• HIPPA Notice Signature Page

Face-to-Face Meeting Forms

• Fund A Face-to-Face Checklist

• Face-to-Face Packet

• Consumer Statement

• Rights and Responsibilities Form- Low-Income/Head-Start/Former TANF

  • Español

• Authorization for Release of Information 

  • Español

• HIPPA Notice Signature Page

• Parent/Caretaker and Related Provider Attestation

• Current Provider Information

• A Parent's Handbook to Subsidized Child Care

• How to Find, Choose, and Pay For High-Quality Child Care: A Guide for Families (PDF)

  • Español