Subsidy, Resource & Referral Program 
PRELIMINARY APPLICATION 
 
 
 
 
                                                    
 
              Application No.: ____ 
NAME OF APPLICANT:  __________________________  SS#________________________(required)           
 
  MAILING ADDRESS: _______________________________________ 
 
   EMAIL ADDRESS:       ______________________________________ 
 
TELEPHONE NOS.: ____________________         _________________   ________________ 
                                              WORK                                         CELL                             HOME 
 
PLACE OF EMPLOYMENT: _______________________________Phone#________________ 
 
SCHOOL OR TRAINING PROGRAM: _____________________________________________ 
 
ARE YOU A TEEN PARENT?             YES          NO 
 
ANNUAL INCOME: $_____________   CHILD SUPPORT INCOME: $_______________ 
 
FAMILY SIZE: _______ 
 
Name of the child (ren) requesting assistance 
Date of Birth 
1. 
 
 
2. 
 
 
3. 
 
 
4. 
 
 
5. 
 
 
 
Provider of Choice: _______________________________________________________ 
 
I hereby certify that the above information is correct and true.  I understand that the information will be 
verified.  I also understand that deliberate false information will result in a delay or disqualification of 
my childcare subsidy. 
 
______________________ 
 
 
 
 
__________________ 
    Signature of Applicant 
 
 
 
 
 
 Date 
 
 
Official use only 
[ ] ELIGIBILITY   [ ] COMPLETED   [ ] NO LONGER INTERESTED   [ ] NO SHOW   [ ] OTHER 
 
[ ] INELIGIBILITY   [ ] INSUFFICIENT HOURS   [ ] NOT IN COMPONENT  [ ] OVERQUALIFIED     
If you are found eligible, you will be placed on the waiting list upon the availability of funds; however, if you are ineligible, you will 
be notified. 
 
Check one 
Single 
 
Married 
 
Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930  
#129 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 772-7147