CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DECLARATION OF EXEMPTION FROM TRUSTLINE
COUNTY USE ONLY
REGISTRATION AND HEALTH AND SAFETY
CASE NAME
SELF-CERTIFICATION
CLIENT CASE NUMBER
INSTRUCTIONS: This form is for an aunt, uncle, or grandparent who is providing child
care. You do not need to be licensed or TrustLine-registered to get state child care
reimbursements. But if you are not licensed or TrustLine-registered, you must fill out this
WORKER NAME
form. This form must be completed and returned promptly to the County Welfare
Department, Alternative Payment Program, or other payment agency.
WORKER NUMBER
1. Name of Provider ______________________________________ Provider’s Date of Birth _______/ ______/________
(PERSON WHO WILL CARE FOR CHILDREN)
Address
City
State_____Zip
___________________________________________
______________________
________________
Phone (
)
_____________________________
The State of California requires proof that you are 18 years of age or older. Please attach a copy of your drivers license
or other proof of age.
2. List the name and address of the family for the children you are providing child care.
Name of Parent/Responsible Adult____________________________________ Phone (
) __________________
Address_______________________________ City _______________ State _____________ Zip ________________
3. Child care will be provided in (Check one):
Child’s Home
Provider’s Home
I declare under penalty of perjury under the laws of the State of California that I am by blood, marriage or court decree the
Aunt
Uncle
Grandparent
of _______________________________, _____________________________,
________________________________,
NAME OF CHILD
NAME OF CHILD
NAME OF CHILD
________________________________, _____________________________,
________________________________,
NAME OF CHILD
NAME OF CHILD
NAME OF CHILD
________________________________, ______________________________ for whom I am providing child care.
NAME OF CHILD
NAME OF CHILD
I understand that because I am an aunt, uncle, or grandparent of the child(ren) listed on this form, I am not required to apply
for TrustLine-registration and am not required to complete the Health and Safety Self-Certification.
I understand that I am not an employee of the County Welfare Department, Alternative Payment Program or other Payment
agency.
I understand that giving false or incomplete information can result in being charged with a crime with penalties of fine,
imprisonment, or both.
Signature of Provider ____________________________________________________ Date________________________
I declare that I am the parent/responsible adult of the child(ren) listed on this form, that I have read the declaration of my
child care provider and that I attest that the declaration regarding the provider’s relationship to my child(ren) is true.
I declare under penalty of perjury under the laws of the State of California that the information I provided on this page is true
and correct to the best of my knowledge. I understand that giving false or incomplete information can result in being charged
with a crime which can include penalties of a fine, imprisonment, or both.
Signature of Parent/Responsible Adult __________________________________________ Date ____________________
COUNTY OR APP USE ONLY
Return this form by:_____________________ to:
CCP 1 (3/15) REQUIRED FORM - SUBSTITUTES PERMITTED