Child Care Assistance Change In Status Reporting Form
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1Child Care Assistance Change in Status
Reporting Form
Any changes in employment, household members, marital or school status, child care arrangements or a
change in child care providers must be reported to Child Care Services in writing within 10 days. Failure to
report changes may result in an overpayment of benefits which are subject to recovery by the Division of
Child Care Services.
For your convenience, you may report changes using this form. If you need additional room you may use the
back of this form or attach a separate sheet of paper.
Name printed:_______________________________________________________________________________
Address: ________________________________________________ Telephone number: __________________
Employment Change
Last place of work______________________ Date employment ended___________________
Current employer_______________________ Date employment began__________________
(For each new place of employment, attach a signed statement from your employer indicating the number of hours
per week you will be working and the rate of pay per hour.)
What days of the week do you work? (circle all that apply) Mon Tues Wed Thurs Fri Sat Sun
What times do you work? (example 8am-5pm)_____________________________________________
Household Member Change
Name______________________ Date of Birth___________ Relationship____________
Adding
Removing
Name______________________ Date of Birth___________ Relationship____________
Adding
Removing
Marital Status Change (Please Explain)
_____________________________________________________________________________________
_____________________________________________________________________________________
School Status Change
Place of Education or Training__________________ Starting Date____________ Ending Date_____________
(Please attach an official copy of your school schedule indicating days of the week and start and end time for each
class.)
Child Care Provider Change
Name of new provider: _____________________________________________ Provider Phone: _____________________
Provider address: _______________________________________________ City: ________________________________
Provider ID Number______________________ Cost of care per child: $__________________ ______________________
Type of provider
(circle): Regulated In-Process
In-Home
Informal Care
Relative (list relationship to child) _______________________
Does this provider care for all your children?
Yes
No
: _______________________________
(if no, list those cared for)
What days and hours does this provider care for your children? ________________________________________________
When did the provider begin caring for your children? _______________________________________________________
On what date did your previous child care provider stop providing care?_________________________________________
Mail, Fax or E-mail Completed Form to:
Child Care Services, Department of Social Services, 910 E. Sioux Avenue, Pierre, SD 57501-3940
Fax: (605) 773-7294 E-Mail: CCS@state.sd.us
July 2014
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