The ACS 1069 form is a one-page income verification document you give to your employer so their payroll department can report your last three months of earnings directly to the New York City Administration for Children’s Services, which uses that information to decide whether your family qualifies for a subsidized child care voucher.1New York City Administration for Children’s Services. Child Care Eligibility Wizard You sign the short consent section at the top, your employer completes the detailed payroll table, and the finished form goes to ACS as part of your voucher application package.
When You Need This Form
ACS requires income verification from every family applying for a child care voucher. Pay stubs usually do the job, but not everyone has them. You might be paid in cash, work irregular hours, or have started a new job before a full pay cycle. The ACS 1069 fills that gap by having your employer report your earnings on your behalf.1New York City Administration for Children’s Services. Child Care Eligibility Wizard
You may also need it at your annual recertification if your pay stubs are incomplete or you’ve changed jobs since your last eligibility review. Missing the recertification deadline in your annual packet results in losing your child care benefits.2Administration for Children’s Services. Apply for Child Care
One boundary to flag: if you’re self-employed, this isn’t the right form. ACS uses a separate self-employment income attestation (CFWB-031) for that situation.
Where to Download the Form
The form is available as a free PDF on the ACS child care eligibility forms page at nyc.gov.1New York City Administration for Children’s Services. Child Care Eligibility Wizard The version hosted there is labeled CS-1069 (also referenced as ECE-015), last revised January 2016.3NYC Administration for Children’s Services. ACD 1069 – Referral to Employer for Employee Income Information
ACS has since introduced an updated version of the same employer income referral under form number CFWB-015, revised April 2024. It asks for 12 weeks of gross payroll data instead of three months and uses updated formatting, but it serves the same purpose.4NYC Administration for Children’s Services. CFWB-015 Referral to Employer for Employee Income Information If your caseworker or the application portal specifies a version, follow their direction. Otherwise, the CFWB-015 is the more current document.
What You Fill Out
Your part is the top of the form. It’s essentially a consent statement authorizing your employer to release your income information to ACS. You enter:3NYC Administration for Children’s Services. ACD 1069 – Referral to Employer for Employee Income Information
- Your full name, printed, matching the name on your child care application exactly.
- Your employer’s name, printed. Write the company, organization, or business owner’s name.
- Your home address, including street, apartment number, city, state, and zip code.
- Your signature and the date. Without the signature, most payroll departments won’t complete their section.
Once signed, hand or email the form to your supervisor, HR contact, or payroll department. They take it from there.
What Your Employer Fills Out
The employer section is the substance of the form. The payroll or personnel department verifies your employment details and reports your gross earnings. Required fields include:3NYC Administration for Children’s Services. ACD 1069 – Referral to Employer for Employee Income Information
- Period of employment, start date and end date. If you’re still employed, the current date goes in as the end date.
- Return-to-work date, filled in only if you’re currently on leave.
- Type of work, a brief job description.
- Regular employment schedule, with typical hours for each day Monday through Sunday.
- Gross income and pay frequency (weekly, bi-weekly, semi-monthly, or monthly).
- Gross hourly income, before deductions.
- Gross payroll for the past three months, broken out by period ending date, hours worked, gross income, overtime, tips, and other earnings.
- Business information: employer name, address, phone, and federal tax ID number.
- Employer signature, title, and date.
Pay attention to the tipped-worker rule. If the amount earned in tips cannot be verified or documented, ACS will calculate 15 percent of gross income and add it to your reported earnings.3NYC Administration for Children’s Services. ACD 1069 – Referral to Employer for Employee Income Information That can push your reported income higher than your actual earnings, so if you work for tips, ask your employer to document them accurately in the payroll table rather than leaving the field blank.
The form also notes that ACS may call your employer to verify what’s reported.3NYC Administration for Children’s Services. ACD 1069 – Referral to Employer for Employee Income Information Give your supervisor or HR contact a heads-up so they’re ready for a potential call.
How to Submit the Completed Form
The form doesn’t go to ACS on its own. You submit it as part of your child care voucher application package along with other documents proving family size, residency, and reason for care. ACS verifies eligibility based on everything together.2Administration for Children’s Services. Apply for Child Care
You have two submission options:
- Online through MyCity at mycity.nyc.gov. Upload the completed form with the rest of your application. Don’t also mail a paper copy. Duplicate submissions slow down processing.
- By mail. Print the application from the ACS forms page and send the full package to NYC Children – EDU, PO Box 40, Maplewood, NJ 07040.
Two groups follow a different path. Families receiving cash assistance should contact their HRA Benefits Access Center to apply. Foster families and families receiving prevention or protective services don’t apply directly; their caseworker or case planner submits a referral to ACS’s Division of Child and Family Well-Being on their behalf.2Administration for Children’s Services. Apply for Child Care
What Happens After You Submit
ACS eligibility determinations take roughly 10 to 15 days once a complete application and income documentation are received.5NYC City Council. Current Status of Child Care Voucher Waiting List and Renewals A missing employer signature or an incomplete payroll table will delay things, so look over the form before you send it.
Being found eligible and actually getting a voucher are two different things. Due to insufficient funding, ACS is no longer able to offer immediate vouchers to families not receiving cash assistance, and eligible non-cash-assistance families are placed on a waitlist.2Administration for Children’s Services. Apply for Child Care Families on cash assistance, foster parents, and those receiving child welfare services are exempt from the waitlist. The practical move is to submit as early as you can and know there may be a wait.
If Your Application Is Denied
If ACS denies your subsidy, whether because of the income reported on your form or another issue, you have the right to request a fair hearing through the New York State Office of Temporary and Disability Assistance. The request must be filed within 60 days of your denial notice. The denial letter itself includes the form and instructions for requesting the hearing, and you can also start the request online at otda.ny.gov/hearings or by phone at (800) 342-3334.6NYC311. Public Benefit Fair Hearing
If the denial came from income figures you believe are wrong, for example tips estimated at 15 percent of gross when your actual tips were lower, bring corrected payroll records to the hearing. Specific documentation gives you the best shot at reversal.