Resident: Verification of Dependent Care Expense

Arkansas County Housing Authority
P 870.946.2622
Monday - Friday • 8:00 am - 4:30 pm
105 W. 4th Street • P.O. Box 447 • DeWitt AR, 72042
[email protected]

Equal Housing, Handicap Accessible, and Accessibility Icons.

Print-Only Form
This form is intended for printing and cannot be submitted online.
Please print, complete, and return it to the ACHA Office.

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Day","name":"Amount-per-Day","value":"$","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Amount per Week","name":"Amount-per-Week","value":"$","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Amount per Month","name":"Amount-per-Month","value":"$","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"header","subtype":"h4","label":"Children in Dependent Care:","className":"d-block"},{"type":"text","required":true,"label":"Dependent Care Participant 1 First Name","name":"Dependent-Care-Participant-1-First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Dependent Care Participant 1 Last Name","name":"Dependent-Care-Participant-1-Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Dependent Care Participant 1 Age","name":"Dependent-Care-Participant-1-Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 2 First Name","name":"Dependent-Care-Participant-2-First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 2 Last Name","name":"Dependent-Care-Participant-2-Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 2 Age","name":"Dependent-Care-Participant-2-Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 3 First Name","name":"Dependent-Care-Participant-3-First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 3 Last Name","name":"Dependent-Care-Participant-3-Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 3 Age","name":"Dependent-Care-Participant-3-Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 4 First Name","name":"Dependent-Care-Participant-4-First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 4 Last Name","name":"Dependent-Care-Participant-4-Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Dependent Care Participant 4 Age","name":"Dependent-Care-Participant-4-Age","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","required":true,"label":"Street Address of Caregiver","name":"Street-Address-of-Caregiver","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"City of Caregiver","name":"City-of-Caregiver","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"State of Caregiver","name":"State-of-Caregiver","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Zip Code of Caregiver","name":"Zip-Code-of-Caregiver","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Print First Name of Caregiver","name":"Print-First-Name-of-Caregiver","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Print Last Name of Caregiver","name":"Print-Last-Name-of-Caregiver","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Telephone of Caregiver","name":"Telephone-of-Caregiver","className":"col-lg-4"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","required":true,"label":"Signature of Caregiver","name":"Signature-of-Caregiver","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Date of Caregiver Signature","name":"Date-of-Caregiver-Signature","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Signature of Parent/Guardian","name":"Signature-of-ParentGuardian","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Date of Parent/Guardian Signature","name":"Date-of-ParentGuardian-Signature","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"By our signatures above, we state that the information provided is true and correct and that we acknowledge that any willful false statements or misrepresentations are a criminal offense.","className":"d-block"}]