Section 1 - Contact Information

Items in Purple are required

What county do you live in?

Clark County, Indiana Floyd County, Indiana Harrison County, Indiana Breckinridge County, Kentucky Bullit County, Kentucky Grayson County, Kentucky Hardin County, Kentucky Henry County, Kentucky Jefferson County, Kentucky Larue County, Kentucky Marion County, Kentucky Meade County, Kentucky Nelson County, Kentucky Oldham County, Kentucky Shelby County, Kentucky Spencer County, Kentucky Trimble County, Kentucky Washington County, Kentucky (Click here for choices)

(If your county is not listed, your are not eligible to apply for this service with 4-C.) To find the agency who serves your area click here.

First Name
Last Name
Last 4 Digits of Social Security Number
Address
City
State	Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose)
Zip / Postal Code
Home Phone
Other Phone
E-mail

Number of children in your household for whom your household has custody.

Date of birth of all children in household (mm/dd/yy)

yes
no

Employment

Employer Name
Work Phone Number (include extension)
How many hours per week do you work?

How much do you make per hour?

*salaried, conmissioned or other types of employees should enter their average monthly income.

Employer Name
Work Phone Number (include extension)
How many hours per week do you work?
How much do you make per hour?

*salaried, conmissioned or other types of employees should enter their average monthly income.

yes
no

If yes, and you participate in an internship, practicum or student teaching program please indicate the number of program hours per week?

yes
no

If no go to Section 3

Section 2 - Other Parent or Spouse's Contact Information

First Name
Last Name

yes no

Employment

Other Parent Employer Name
Other Parent Work Phone Number
How many hours per week does the other parent work?

How much does the other parent make per hour?

*salaried, conmissioned or other types of employees should enter their average monthly income.

Employer Name
Work Phone Number (include extension)
How many hours per week does the other parent work?
How much does the other parent make per hour?

*salaried, conmissioned or other types of employees should enter their average monthly income.

yes no

If yes, and he or she participates in an internship, practicum or student teaching program please indicate the number of program hours per week?

Section 3 - Other Income

Do you or the other parent in household receive child support?

yes
no

If yes, enter the average amount received per month

Monthly Amount

yes
no

If yes, enter the average amount paid per month

Monthly Amount

SSI

If any members of your household receive SSI please indicate the monthly amount

You
Other parent
Children

KTAP or TANF

Do you or the other parent receive KTAP or TANF?

yes
no

Do any of the children in your household receive KTAP or TANF?

yes
no

If yes, enter monthly amount

Monthly amount

Monthly amount
Type of income
Household member receiving