Form Cc43 - Child Care Provider Report Of Change Page 2
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2APPROVED NON RELATIVE AND APPROVED RELATIVE CHILD CARE PROVIDERS ONLY
CHANGE IN INDIVIDUALS LIVING IN THE CHILD CARE LOCATION: A valid criminal history check, based on the
provider type, is required for all individuals 16 years of age and older. Individuals 16 years of age and older who are no
longer living in an Approved Non Relative child care location must be terminated from the providers New Alaska
Background Check System case.
New individual living in the child care location
or
Individual no longer living in the child care location
First, Middle, Last Name
Social Security
Birth
Age
Relationship
Date moved
Number
Date
to Provider
in/out of child
care home
Moved In or
Moved
Out
Date:
Moved In or
Moved
Out
Date:
Moved In or
Moved
Out
Date:
APPROVED RELATIVE PROVIDERS ONLY
CHANGE OF CHILDREN IN CARE: If the children in your care are different than what you reported on your Child Care
Assistance Approved Relative Provider Application, list the names of the children who are no longer in your care and the
date care ended. Also list new children in your care and when care will begin.
Child’s First, Middle, Last Name
Child’s Date of
Age
Relationship
Date care to
Birth
to You
begin / end
Begin or
End
Date:
Begin or
End
Date:
Begin or
End
Date:
Begin or
End
Date:
Begin or
End
Date:
Begin or
End
Date:
Begin or
End
Date:
Begin or
End
Date:
IN-HOME CHILD CARE PROVIDERS ONLY
CHANGE OF IN-HOME CAREGIVER
Current Caregiver Name
Last date providing care:____________________
___________________________________
You must terminate this individual from your New Alaska Background Check System provider case.
New Caregiver First, Middle, Last Name
_______________________________________________________________
Caregiver Date of Birth:__________________
Date care to begin:________________________
Attach a completed In-home Child Care Application and In-home Child Care Parent / Caregiver Agreement along with a copy of the
caregiver’s government issued photo identification. You must ensure this individual has a valid criminal history check through the
Alaska Background Check Program prior to care beginning.
CC43 (06-4071) Rev 07/15
Page 2 of 2
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