Child Care Benefit Form - Ohio
Second Caretaker’s Employment *
Name and Address of Employer (enter “Self” if self-employed)
Start Date
Rate of Pay
How often paid
Job Title or Description
Supervisor’s Name
Phone Number
* You must attach proof of your employment income, such as check stubs, for the last 30 days. If you are starting new
employment, attach a statement from your employer on company letterhead or on a form you get from the county department of job
and family services. The employer's statement must show your start date, rate of pay, how often paid and work schedule. If you
have been self-employed over the last year, include the previous year's tax return. If you have been self-employed for less than a
year, include an itemized list of income and expens es which are directly related to the production of goods or services.
If you do not provide the necessary documentation, this application for child care benefits will be denied.
Days of Work
(Check all that apply)
Hours of Work
If Hours Vary, Show Average
Number of Hours per Day
Sunday Begin End Begin End
Monday Begin End Begin End
Tuesday Begin End Begin End
Wednesday Begin End Begin End
Thursday Begin End Begin End
Friday Begin End Begin End
Saturday Begin End Begin End
Second Caretaker’s School or Training
Name and Address of School or Training Location
Start Date
Contact Person
Phone Number
Days of
School/Training
(Check all that apply)
Hours of School and/or Training
If Hours Vary, Show Average Number of
Hours p er Day
Sunday Begin End Begin End
Monday Begin End Begin End
Tuesday Begin End Begin End
Wednesday Begin End Begin End
Thursday Begin End Begin End
Friday Begin End Begin End
Saturday Begin End Begin End
Estimated date of graduation or completion of training
JFS 01138 (Rev. 2/2015) Page 5 of 10
Page 5/12
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Child Care Benefit Form - Ohio PDF
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