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Home » Your Child Care Resources » Prescreening Questionnaire

Child Care Prescreening Questionnaire

The Child Care Assistance Program helps low income families who are working or attending training or education programs. Funding for child care assistance comes from federal programs, which require us to collect information on all aspects of your household income, the family members in your household, and all work or training activities for each adult living in your home.

The following questions will determine whether you are eligible for child care assistance. Please complete the form and follow the instructions on the next page. If you have questions about the process or need help completing the prescreening questionnaire, please contact a child care specialist at 1-800-234-9306.


1. Do you live in one of the following counties?
Collin Erath Johnson Palo Pinto Somervell
Denton Hood Kaufman Parker Wise
Ellis Hunt Navarro Rockwall  
2. Select one of the following situations.
I am in a two-parent household. My spouse/significant other and I are both currently working and/or in job training or attending an educational program for a combined average of 50 hours or more per week.
I am a caregiver for the child of a person deployed in the military.
None of the above
3. Is your monthly income below the income guidelines outlined in the table below? Be sure to include all money received – work, child support, Social Security, etc., before taxes.


Family Size Gross Monthly Income
2 $3,264
3 $4,032
4 $4,799
5 $5,567
6 $6,335
7 $6,479
8 $6,623
9 $6,767

North Central Texas Council of Governments | 616 Six Flags Drive P.O. Box 5888 Arlington, TX 76005-5888
Main Operator: 817-695-9184 | 1-888-548-WORK | Fax: 817-640-6480
Relay Texas: 711 | TDD: 1-800-735-2989 | Voice: 1-800-735-2988
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