Form Id 4853a - Child Development And Care (Cdc) Program Application Additional Space For Application - Michigan Department Of Education

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Michigan Department of Education
Child Development and Care (CDC) Program Application
ADDITIONAL SPACE FOR APPLICATION
PURPOSE
: Attach this document to your Michigan Child Development and Care (CDC) Application if you
need extra space to complete any of the sections in the application. This is an optional document, and
you do not need to complete this if not needed. The Michigan CDC Application can be found at:
INSTRUCTIONS
:
Use this form only if you need extra space to complete any of the sections in the application. You only
need to fill in the sections where you need extra space. Attach this form to your completed Michigan CDC
Application. Instructions for submitting the Michigan CDC Application are included on the application.
SECTION 1: APPLICANT INFORMATION
Last Name
First Name
Middle Name
SECTION 2: EXTRA SPACE FOR PERSONS LIVING IN YOUR HOME
Tell us about all the adults living in your home.
List all additional adult members of your household. Include family members who do not live with you, but are
expected to return to your home. You do not need to list the person applying.
Name (First, Middle, Last):
Date of Birth
U.S. Citizen?
Gender
Relationship to
SSN (optional)
Receive MDHHS
Receive SSI
you:
cash assistance?
benefit?
Yes
M
Yes
Yes
No
F
No
No
Name (First, Middle, Last):
Date of Birth
U.S. Citizen?
Gender
Relationship to
SSN (optional)
Receive MDHHS
Receive SSI
you:
cash assistance?
benefit?
Yes
M
Yes
Yes
No
F
No
No
Name (First, Middle, Last):
Date of Birth
U.S. Citizen?
Gender
Relationship to
SSN (optional)
Receive MDHHS
Receive SSI
you:
cash assistance?
benefit?
Yes
M
Yes
Yes
No
F
No
No
4583a
Pg. 1 of 4
Form ID
ATTACH TO YOUR CDC APPLICATION

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