Application Form & Full Disclosure Of Ownership Statement For An Amended License By A Non-Profit Corporation Or Governmental Unit Page 6
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6SECTION b - OWNERSHIP INFORMATION:
IF ANY CHANGES ARE MADE TO THIS SECTION, NOTE ON APPLICATION.
When we use the term “ownership of your child care/preschool program” we are not referring to the building, we are referring to
the actual child care program. If you are unsure, some questions you might ask yourself are: who is financially responsible for the
operation of the program? Who or what entity is responsible for hiring the Director? You should also consider consulting with your
accountant or attorney for their advice.
13. Ownership of Program:
Enter legal name of Non-Profit Corporation or Governmental Unit..
14. Federal Identification Number:
Federal ID Numbers will not be released without the individual’s consent except as required by law. (If no Federal ID Number,
enter the word “None”).
15. Secretary of State Account Number:
This is an assigned Number when you register your business ownership (Corporation or Limited Liability Company) with the
Secretary of State’s Office. (If you have no SOS Account Number, enter the word “None”).
16. Mailing address if different than #11 in Section A above:
Enter the mailing address if different from mailing address in Section A. Include Street Address, PO Box # (if applicable),
City, State, County and Zip Code. When both addresses are the same, enter the word “same”.
17. Phone Number/Cell Phone Number with Area Code if different than #3 in Section A above:
Enter the phone number/cell phone if different from the phone number/cell phone number in Section A. When both phone
numbers are the same, enter the word “same”.
18. Email (optional) if different than #5 in Section A above:
Enter the email address if different from the email address in Section A. When both addresses are the same, enter the
word “same”.
SECTION C - FACILITY INFORMATION:
Must complete this section with each amended application.
For Family Child Care Home II, Center, School-Age-Only Center or Preschool. When a Family Child Care Home II, Child Care
Center, School-Age-Only Center or Preschool will not be located in the applicant’s residence, check the appropriate box of where
the program is located. Also indicate whether you rent/lease or own this child care/preschool program location. If applicant is not
the owner of the property, the owner/landlord information must be provided.
SECTION D - HOuSEHOLD INFORMATION:
All license types must complete this section if located in a residence.
This section must be completed for ALL license types located in a residence. Read and complete this section according to the
instructions on the form. You must list all persons (including yourself) who reside or who will be regularly present in the residence.
Relationship examples: spouse, son, daughter, niece, grandmother, etc.
SECTION E - STAFF INFORMATION FOR FAMILY CHILD CARE HOMES II ONLY:
Must complete this section with each amended application.
Read and complete this section according to the instructions on the form. Household members that will be assisting with the child
care/preschool program should also be listed in this section. FTE means full-time employee; PTE means part-time employee.
Refer to the regulations for definition of primary provider, staff, substitute and volunteer.
CRED-0956 (25023) 6/14
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