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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 ChangeNew 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 CareChange 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/TrainingAdditional EmploymentChange 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)OtherREMINDER: Call CCS if you do not hear from them within five (5) days of submitting this form.