Thank you for your interest in the PA Pre-K Counts program. Please return your completed
application along with copies of the following: Please only send copies.
1. Your annual household income
2. Your child’s birth certificate
According to program regulations, annual household income (earned and unearned) is
required to establish eligibility.
The following are included in determining annual income:
a. Most recent W-2 Form (2019) or Most recent tax return (2019) or Pay stubs (last 30 days)
b. Unemployment Financial Determination Letter
c. SSI/Social Security Financial Award Letter
d. Child Support Information documenting (SCDU stub 0or court order) amount
e. Unearned income including cash and contributions, dividends, interest, net income,
net royalties and periodic receipts from estates or trusts.
Please return your completed application to the Private Industry Council / attention Pre-K
Counts. Please note the gray shaded areas on the application are for agency staff only.
Private Industry Council / Pre-K Counts
112 Commonwealth Drive
Lemont Furnace, PA 15456
For questions call: 724-437-2590
Pre-K Counts Staff