Form Cc28 - Substitute Caregiver Verification printable pdf download

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

SUBSTITUTE CAREGIVER VERIFICATION

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 -

location;

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

Date

CC28 (06-4003) Rev 07/15

age 1 of 1

Form Cc28 - Substitute Caregiver Verification

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