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 Change New Address City Zip Code New Contact Information Home Phone Cell Phone Email 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)BirthOtherRemove 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 Days of the WeekMondayTuesdayWednesdayThursdayFridaySaturdaySunday Work hours to Request a Reduction in Parent Share of Cost(Parent will be required to provide documentation) Reason for the reduction Temporary Incapacitation(Parent will be required to provide documentation) Reason for the incapacitation Start Date End Date Temporary Suspension of Child Care(Documentation may be required) Reason for the suspension Start Date End Date OtherREMINDER: Call CCS if you do not hear from them within five (5) days of submitting this form.
