City of Evanston - Child Care Premium Pay Program

Disclaimer: The information provided in this form will be combined with the total population enrolled in child care services and reported to the City of Evanston as a whole to verify provider eligibility for the Child Care Premium Pay program. Child care providers have been asked to capture this information for all families currently enrolled in services to meet the Child Care Premium Pay Program reporting requirements. Providers that serve at least 51% or more children from low/moderate income households could be eligible for higher premium pay awards. This document will remain on file with the child care provider until the Child Care Premium Pay Program is closed out.

Annual Income(Required)
Gross taxable income for all family members 18+
Race/Ethnicity
Race/Ethnicity

Consent(Required)
Name(Required)
Date(Required)