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Change Notification Form

    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) BirthOtherRemove 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 to Request a Reduction in Parent Share of Cost (Parent will be required to provide documentation) Temporary Incapacitation (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.