Child Care Center Change Request - Franklin County Department Of Job & Family Services
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1□ Initial
□ Case Termination
Type of Change:
□ Redetermination
□ Change
Child Care Center
Provider E-mail Address:
Change Request
Case Name
First
Middle
Last
Case Number
Requested Start Date of Care
Street Address
City
State
Zip Code
Provider Name
Provider Address
Provider Vendor Number/ State Id
Primary (P) or
Full time(FT)/
Household
Social Security
Date of Birth
First Name
Last Name
Multiple (M)
Part time (Pt)
Gender
Number
Composition
Month
Day
Year
Male Adult
Female Adult
st
1
Child
nd
2
Child
rd
3
Child
th
4
Child
th
5
Child
th
6
Child
th
7
Child
th
8
Child
Instructions for change:
PLEASE READ BEFORE SIGNING: The undersigned child care provider hereby certifies that the information contained
Provider Signature
Date
herein is true and accurate, and understands that it (child care provider) will be held responsible for any overpayment that
X
occurs as a result of having provided inaccurate and/or misleading information. (To be signed by provider using ink)
Provider Name PRINTED
Telephone Number
The undersigned parent/customer hereby acknowledges that a Child Care Center Change Request form must be signed in
order to initiate services, to add children, and/or to change a schedule, and that the failure to sign may delay or prevent the
processing of the change. By signing this form, I certify that the information contained herein is true and accurate, and
understand that I will be held responsible for any overpayment that occurs as a result of having provided inaccurate and/or
Parent/Customer Signature
Date
misleading information.
X
My signature below also serves as authorization for (Provider Name) ___________________________________________
to provide FCDJFS with information necessary to determine eligibility for publicly funded child care, and/or to monitor or
Parent/Customer Name PRINTED
Telephone Number
evaluate the delivery of said care. Any information shared pursuant to this document shall remain confidential according to
state and federal law. This authorization shall remain in effect, as needed, unless revoked by me in writing. (To be signed
by parent/customer using ink)
*** Documentation of Change MUST be submitted with this form ***
FCDJFS #1401-CC (9/11)
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