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The form collects child demographics, parent/guarantor identity and contact details, employment information, household size, sibling details, and detailed annual income sources. It also requests home and real estate status, mortgage and lender information, annual expenses, medical insurance premium and deductible amounts, policy identifiers, and whether the child is covered. 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If they are long, send the first two pages of each.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is collected for the child and parents/guarantor?",{"text":113,"@type":109},"The form requests the child’s name, DOB, UNC MRN, and SSN, plus parent/guarantor names, DOB, marital status, and whether the child lives with the guarantor, along with full address and contact details.",{"name":115,"@type":106,"acceptedAnswer":116},"How does the form assess financial eligibility?",{"text":117,"@type":109},"It gathers annual income for parents and other sources, calculates total annual income, captures home ownership or rent details, mortgage and lender info, annual expenses, and medical insurance premiums, deductibles, and coverage status.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},304736,1790551811,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},2336477974920,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","For your child to be considered for re-enrollment in the CCCDP Grant Program, this form must be completed in full. This confidential information will be kept private. It is only used to determine eligibility for the program. All questions must be answered to the best of your ability, and the form signed by an adult (parent or guarantor) . ALSO your most recent Federal Tax Forms IRS 1040 and NC State Tax Form D-400, must be submitted. If they are long, just send in the first two pages of each. If you have not filed tax returns for last year, please contact us.  \nDemographics  \nChild’s Name:   DOB:   UNC Medical Record Number (MRN):   SSN:   2nd Child’s Name:   DOB:   UNC Medical Record Number (MRN):   SSN:   Parent \\#1 Name:   DOB:   Parent \\#2 Name:   DOB:   Street Address:   City:   State:   Zip:   Home Phone:   Cell Phone(s):   Email Address(es):   Guarantor Name:   DOB:   Guarantor Marital Status:   Does the child live with the Guarator? Yes No  \nEmployment  \nParent \\#1 Employer:   How long?   Job Title:   Phone:   Parent \\#2 Employer:   How long?   Job Title:   Phone:    \nFamily  \nNumber of persons in household (dependents), including parents:    \nName of sibling \\#1:   Age:   Name of sibling \\#2:   Age:   Name of sibling \\#3:   Age:   Name of sibling \\#4:   Age:    \nAnnual Income  \nParent \\#1 Income:   Parent \\#2 Income:   Other annual income (explain):   Miscellaneous or one-time income (explain):   TOTAL ANNUAL INCOME:    \nHome & Real Estate  \nDo you own or rent your home? Own: Rent:  \nMortgage balance:   Lender:    \nDo you own other real estate: Yes: No:  \nIf yes, describe:    \nAnnual Expenses  \nRent or mortgage (monthly   x 12) Total:   Utilities (power, water, internet, phones):   Vehicle maintenance and fees per year:   Medical expenses (in last year):   Medical debt payment (   x 12) Total:   Medical debt balance still owed:    \nMedical Insurance  \nMedical insurance premiums per year:   Medical insurance deductible per year:   Name of Company:   Subscriber Name:   Is child covered? Yes No Policy \\#:    \nComments (Any other information that you would like to provide about financial need)  \n\n|  |\n| --- |\n|  |\n|  |\n|  |\n|  |\n\nSignature:   Date:    \nBy signing this form you certify that the answers provided above are true to the best of your knowledge. You also understand that fraudulent or misleading information will make you ineligible for any financial assistance. We reserve the right to contact your employer or other holders of financial information.  \nPlease direct all questions related to this application to  \nVelma Grose [at](at velma.grose@unchealth.unc.edu)[ ](at velma.grose@unchealth.unc.edu)[velma.grose@unchealth.unc.edu](at velma.grose@unchealth.unc.edu)[ ](at velma.grose@unchealth.unc.edu)[Phone:](Phone:) (919) 419-1449","cbCaifH5neAO0X4g","https://ap.wps.com/l/cbCaifH5neAO0X4g","pdf",185026,"English","# Demographics\n# Employment\n# Family\n# Annual Income\n# Home & Real Estate\n# Annual Expenses\n# Medical Insurance\n# Comments & Signature","[{\"question\":\"What documents must be submitted with the re-enrollment form?\",\"answer\":\"Submit your most recent Federal Tax Form IRS 1040 and NC State Tax Form D-400. If they are long, send the first two pages of each.\"},{\"question\":\"What information is collected for the child and parents/guarantor?\",\"answer\":\"The form requests the child’s name, DOB, UNC MRN, and SSN, plus parent/guarantor names, DOB, marital status, and whether the child lives with the guarantor, along with full address and contact details.\"},{\"question\":\"How does the form assess financial eligibility?\",\"answer\":\"It gathers annual income for parents and other sources, calculates total annual income, captures home ownership or rent details, mortgage and lender info, annual expenses, and medical insurance premiums, deductibles, and coverage status.\"}]","CCCDP Grant Program Re-enrollment Application Form | PDF",1789816620]