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Change Notification Form

    Are you transferring from a different board area in Texas? *

    YesNo
    Please Note:
    Child Care Services (CCS) will contact you within five (5) business days of receipt of the request.
    Address Change
    New Contact Information
    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
    Change of Income
    (Provide 2-4 check stubs or Wage Verification Form)

    IncreaseDecreaseAdditional Income (bonus, commission, etc.)Second Job (Primary Applicant)Second Job (Spouse)
    Change in Employment/Training
    (Includes Job Loss)

    Job LossNew Employment/Training
    Additional Employment
    Change in Hours
    (Provide a copy of work schedule)


    MondayTuesdayWednesdayThursdayFridaySaturdaySunday
    Work Hours
    Request a Reduction in Parent Share of Cost
    (Parent will be required to provide documentation)
    Temporary Incapacitation
    (Temporarily unable to work due to illness, injury, or maternity leave)
    (Parent will be required to provide documentation)
    Temporary Suspension of Child Care
    (Documentation may be required)
    Other
    REMINDER: Call CCS if you do not hear from them within five (5) days of submitting this form.

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    Parent Information

    Provider Information

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