Form Cc43 - Child Care Provider Report Of Change

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Office Use Only
CHILD CARE ASSISTANCE PROGRAM
Division of Public Assistance
Child Care Program Office
3601 C Street, Suite 140
PO Box 241809, Anchorage, AK 99524-1809
CHILD CARE PROVIDER REPORT OF CHANGE
Printed Provider First and Last Name: _________________________________ ICCIS Number, if known:_____________
Facility Name, if any: ___________________________________________
RATE CHANGE – ALL CHILD CARE PROVIDER TYPES: C
omplete and submit a Child Care Provider Rates and
Responsibilities CC12. Notice must be given to all participating families and the child care assistance / Child Care Program Office at
least 30 days prior to the new rate becoming effective. All rates are effective the first day of the month following the 30 day notice.
CHANGE OF ADDRESS / CONTACT INFORMATION: A 30 calendar day notice must be given prior to a change of
mailing or physical address to the Child Care Assistance Program. Additional paperwork is required as noted below.
MAILING ADDRESS CHANGE:
PHYSICAL ADDRESS CHANGE: Your current
Attach a completed
State of Alaska Substitute Form W9.
approval does not transfer to a new physical location. You
Effective date of change:_____________
must submit a completed Child Care Provider Application
applicable to your provider type, and Get Out Alive! Disaster
New mailing
Preparedness and Emergency Evacuation Plan CC10 form
address:_________________________________________
reflecting the new physical address.
CONTACT PHONE NUMBER CHANGE
Home phone number: ____________________________________
Cell phone number:___________________
Email address:___________________________________________
Fax number:________________________
NAME CHANGE: Attach a completed State of Alaska Substitute Form W9 and a copy of the government issued photo
identification and Social Security card supporting the name change.
Print Provider’s New First, Middle, Last Name: ____________________________________________________________
APPROVED NON RELATIVE, APPROVED RELATIVE, AND IN-HOME CHILD CARE PROVIDERS ONLY
CHANGE IN HOURS OF OPERATION / SCHEDULED CLOSURES
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
_______am/pm
_______am/pm
_______am/pm
_______am/pm
_______am/pm
_______am/pm
_______am/pm
to
to
to
to
to
to
to
_______am/ pm
_______am/ pm
_______am/ pm
_______am/ pm
_______am/ pm
_______am/ pm
_______am/ pm
or
or
or
or
or
or
or
________ 24 hr
________ 24 hr
________ 24 hr
________ 24 hr
________ 24 hr
________ 24 hr
________ 24 hr
SCHEDULED CLOSURES (SUCH AS HOLIDAYS)
: List changes in the days and/or dates you will be closed and not providing
child care services on an annual basis. :_____________________________________________________________________________
___________________________________________________________________________________________________
Provider Signature:___________________________________________
Date:___________________ _______
Additional reportable changes on page 2
CC43 (06-4071) Rev 07/15
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