Change Notification Form Name Contact Number Email Address Please Note: Child Care Services (CCS) will contact you within five (5) business days of receipt of the request.Address ChangeNew Address City Zip Code New Contact InformationHome Phone Cell Phone New Email Address New Relationship StatusIf 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. New Relationship Status Cohabitation (Living Together)MarriedSingleSeparatedDivorcedWidowedNew Dependent or Add a SiblingParent will be required to provide documentation. New Dependent or Add a Sibling BirthOtherRemove Child from CareChild's Name Effective Date Change of IncomeProvide 2-4 check stubs or Wage Verification Form. Change of Income IncreaseDecreaseAdditional Income (bonus, commission, etc.)Second Job (Primary Applicant)Second Job (Spouse)Effective Date Change in Employment/TrainingIncludes Job Loss. Change in Employment or Training Job LossNew Employment/TrainingStart Date Last Day at Previous Employer/Training Additional EmploymentStart Date Change in HoursProvide a copy of work schedule.Start Date Days of the Week MondayTuesdayWednesdayThursdayFridaySaturdaySundayWork hours from Work hours to Request a Reduction in Parent Share of CostParent will be required to provide documentation.Reason for the reduction Temporary IncapacitationParent will be required to provide documentation.Reason for the incapacitation Start Date End Date Temporary Suspension of Child CareDocumentation may be required.Reason for the suspension Start Date End Date OtherOther comments Reminder: Call CCS if you do not hear from them within five (5) days of submitting this form.
