Self-Declaration of Child Support

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Child's Name

First Last

Child's Date of Birth

Primary Parent/Guardian's Name

First Last

Primary Parent/Guardian DOB

Champlain Valley Head Start recognizes that not all families have formal documentation of child support, such as court orders or documentation from the Office of Child Support. Please complete the following statement in order to self-declare the child support you receive. Be sure to include all child support received, even if it is not for the child who is applying to enroll in the program.

Amount of Child Support that you receive:

How often do you receive Child Support?

When did you begin receiving this Child Support Payment?

Primary Parent/Guardian Signature

By signing below, I certify that the information I have provided is accurate and truthful to the best of my knowledge. I understand that intentionally providing false, inaccurate, or incomplete information may result in a loss of my family’s eligibility to participate in the program.

Date