Form Cc28 - Substitute Caregiver Verification


Office Use Only
Division of Public Assistance
Child Care Program Office
3601 C Street, Suite 140
PO Box 241809, Anchorage, AK 99524-1809
Substitute Caregiver Information. Please attach a copy of your government issued photo identification:
Print First, Middle, Last Name:______________________________________________________________
Alias: ___________________________________Date of Birth:___________ SSN:____________________
Mailing Address: ________________________________City:____________________ Zip: ____________
Physical Address: _______________________________ City:____________________ Zip: ____________
E-mail Address: _______________________________________________________
Substitute caregiver’s relationship (degree of kinship) to children in care, if any: __________________
Initial the line at the beginning of each statement to indicate you have carefully read each statement below.
I have read, understand, and am capable
_____ All child care services provided will be
of fulfilling the responsibilities and
conducted at the Provider’s approved
requirements of 7 AAC 41.200 -
7 AAC 41.255;
_____ Any pay or other compensation for child care
I understand I must complete the
services will be made to me by the listed
applicable process to have a valid
provider, and not families using care;
criminal history check before I can be
_____ I cannot submit billing reports to the State of
considered eligible;
Alaska for payment of my services; and
I cannot provide child care services
_____ I cannot provide child care services for more
until I have received approval from the
than 30 days in any 12-month period.
Child Care Assistance Program;
Provider Information: Provider Type: □ Approved Non-Relative □ Approved Relative
Name of Provider: ________________________________________________________________________
Provider’s Physical Address:______________________________ City:________________ Zip:_________
Provider’s Phone Number: _______________________
Certification and Statement of Truth
Under penalty of perjury or unsworn falsification, I certify that the above named substitute caregiver has read,
understands, and is capable of fulfilling these responsibilities in my absence. I will ensure the substitute caregiver
does not provide care for more than thirty (30) days in any twelve (12) month period. The statements made on this
document regarding myself and the substitute caregiver are true and correct.
Provider Signature
CC28 (06-4003) Rev 07/15
age 1 of 1


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