ChildCareGroup | Child Care Assistance: Change Req Form


		Main Page
		Child Care Assistance (CCA)
		Are You Eligible? Types of Child Care Application Form Change Notification Form Attendance Card Info Attendance Card Management Special Needs/Inclusion FAQs Helpful Info & Resources Contact CCA
		Resource & Referral
		Food & Nutrition
		CENTER OPERATIONS
		Success Stories
		Home Page

Child Care Assistance
Change Notification Form

First Name:
Last Name:
Last 4 digits of Social Security #:
Spouse Name ( if applicable):
Contact Number:
E-mail Address:
Date of Birth:	(mm/dd/yyyy)

Requested Change: please check the appropriate box or boxes below

Mailing Address
Physical Address

Address:		City:
State:		Zip Code:

New Contact Numbers

Change to members in the household (such as, new baby, change in marital status, etc.)

Request - New Child Care Provider

Child care authorizations typically begin at the beginning of each month. If your situation is an emergency, please contact our office at 214.630.5949
You must go to the requested facility and complete all of their facility documents before child care start.
All co-payments must be paid in full before the transfer can be approved

Note: Please do not start child care at the new facility until you have heard from CCA. We must authorize child care at the new facility.

Change of Income

IncreaseDecreaseAdditional Income

Effective Date:	(mm/dd/yyyy)
List Additional Income (if applicable)

Change in Employment/Training

Start Date:	(mm/dd/yyyy)
Last Day at previous Employer/Training:	(mm/dd/yyyy)

Additional Employment

(mm/dd/yyyy)

Change in Hours

Temporary Reduction of Co-payment

Reason for the reduction:

Note: Backup documents may be required to verify your need for assistance.