Form Cc32 - Child Care Grant Request To Save Funds For A Future Purchase printable pdf download

Office Use Only

CHILD CARE GRANT PROGRAM

Division of Public Assistance

Child Care Program Office

3601 C Street, Suite 140

PO Box 241809, Anchorage, AK 99524-1809

CHILD CARE GRANT

REQUEST TO SAVE FUNDS FOR A FUTURE PURCHASE

Facility Name: _________________________________________________ Phone: ____________________________

Mailing Address: ___________________________________________________________________________________

City: ______________________________ Zip Code: ___________________ ICCIS Number: _________________

I am requesting to save funds received through the Child Care Grant (CCG) Program to make a future large purchase. I

understand the purchase must be made in the same state fiscal year (July 1 through June 30) in which the approval to save

was granted. The item(s) I am requesting to save for are:____________________________________________________

Based on my past CCG reimbursements and monthly attendance I anticipating saving $ ___________ for the months

of_______________________ allowing for the purchase to be made in _____________(Month/Year).

I understand the receipt for this purchase must be submitted by the last day of the month following the above agreed upon

purchase month. Under penalty of perjury, I certify that all information contained in this form is true and correct to the

best of my knowledge.

___________________________________________

_______________________________________________

Printed Name if individual with CCG signing authority

Signature of individual with CCG signing authority

Date:___________________

CHILD CARE GRANT

REQUEST TO APPLY FUNDS TO A PAST PURCHASE

Facility Name: _________________________________________________ Phone: ___________________________

Mailing Address: ___________________________________________________________________________________

City: ______________________________ Zip Code: ___________________ ICCIS Number: _________________

Child Care Grant funds which I may be eligible to receive in the month(s) of _________________ are requested to be

applied to a past purchase. The purchase during the current state fiscal year was made on ___________ (Month Day,

Year) and is in use at my child care facility. A copy of my receipt for this purchase is attached.

Item(s) Purchased: __________________________________________________________________________________

Under penalty of perjury, I certify that all information contained in this form is true and correct to the best of my

knowledge.

____________________________________________

_______________________________________________

Printed Name if individual with CCG signing authority

Signature of individual with CCG signing authority

Date:___________________

CC32 (06-4028) Rev 04/15

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Form Cc32 - Child Care Grant Request To Save Funds For A Future Purchase