Child Care Assistance Program Change Of Eligibility Form
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1Child Care Assistance Program Change of Eligibility Form
Client Name: ____________________________________________ CCAP Caseworker: _______________________
Please notify your caseworker in writing 15 days in advance of changes. Please include written verification of the
changes with this form if needed. If you do not report changes, you may owe a recovery of child care benefits received
or no longer be able to receive assistance with your child care.
Check the box in the left hand column for those changes that have occurred and complete the blanks on the right with the
specific information.
Employment: Verification of Employment, Termination, or Leave form completed by employer must be turned in to CCAP
nd
Me
2
Parent
Work hours increased/decreased to _______________________ per week.
(Circle one)
Salary/Income has changed to $_________________ per month (before taxes).
New Job: _______________________________________________________________________
Employer Name
Address
Phone Number
Work Schedule change (Enter new schedule)
Sun
Mon
Tues
Wed
Thur
Fri
Sat
Total Hrs
per week
School/Training: Letter from school or program with changes must be turned in to CCAP.
School/training hours increased/decreased to ____________________ hours per week.
(Circle one)
Family Income (other than wages):
Previous
Current
Type of Income_____________________________________
$ __________
$ ________
Provider:
Provider Change (Please notify your case worker 15 days before changing providers):
Name & License # of new provider: _________________________________ Phone: ____________________
For Child(ren): ________________________________ Start date for new provider: _____________________
Child care schedule change (Enter new schedule. Schedule cannot exceed the maximum number of hours of
care for which you are eligible.)
Sun
Mon
Tues
Wed
Thur
Fri
Sat
Total Hrs
per week
Family Size Changes: Proof of Citizenship (birth certificate, etc.) for new children must be turned in to CCAP.
My family is larger/smaller ___________________________________________________________________
Name of new/leaving member
Relationship to me
Date of birth
(Circle one)
Changes in Address/Phone: Proof of residency (copy of current lease or utility bill) must be turned in to CCAP.
New address: ______________________________________________________________________________
# / Street
City, State
Zip Code
New Phone Number: ________________________
Other Comments/Changes: ________________________________________________________________________
_________________________________________________________________________________________________
Thank you for completing this form. If you have any questions, contact your Child Care Assistance Program at the Denver
County Department of Human Services at 720-944-5437 or by email at .
I certify that the information I have filled in on this form is correct.
________________________________________________________________________________
_
Client Signature
Social Security Number
Date
2/26/2015
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