A Decrease font size. A Reset font size. A Increase font size. Go Back Home> Program Services> Child Care Services> Change Notification Form> Change Notification Form Your Name * Contact Number * Your Email * Please Note: Child Care Services (CCS) will contact you within five (5) business days of receipt of the request. Address Change New Address: City: Zip Code: New Contact Information Home Phone: Cell Phone: E-Mail Address: New Relationship Status (If selecting “Married”, provide a copy of the marriage certificate, the spouse’s social security number*, and the Spouse’s Date of Birth. If applicable, add spouse to Food Stamps case.) Cohabitation (Living Together)MarriedSingleSeparatedDivorcedWidowed New Dependent or add a Sibling (Parent will be required to provide documentation) BirthOther Remove Child from Care Child’s Name: Effective Date: Change of Income (Provide 2-4 check stubs or Wage Verification Form) IncreaseDecreaseAdditional Income (bonus, commission, etc.)Second Job (Primary Applicant)Second Job (Spouse) Effective Date: Change in Employment/Training (Includes Job Loss) Job LossNew Employment/Training Start Date: Last Day at Previous Employer/Training: Additional Employment Start Date: Change in Hours (Provide a copy of work schedule) Start Date: MondayTuesdayWednesdayThursdayFridaySaturdaySunday Work Hours Start Time: End Time: Request a Reduction in Parent Share of Cost Reason for the reduction: (Parent will be required to provide documentation) Temporary Incapacitation (Temporarily unable to work due to illness, injury, or maternity leave) Reason for the incapacitation: Start Date: End Date: (Parent will be required to provide documentation) Temporary Suspension of Child Care Reason for the suspension: Start Date: End Date: (Documentation may be required) Other REMINDER: Call CCS if you do not hear from them within five (5) days of submitting this form. Child Care Services Apply for Child Care Assistance Child One Resource Map Contact CCS Parent Information Provider Information
