Form Cc-200-A - Certified Family Child Care Provider Application
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Page 1 of 2
CC-200-A-FF (8-17)
Child Care Administration
CERTIFIED FAMILY CHILD CARE PROVIDER APPLICATION (Addendum)
This is to be used for additional Household Members and Adult and Minor Children Out-of-Home from the CC-200.
APPLICANT’S FULL LEGAL NAME (Last, First, Middle)
HOUSEHOLD MEMBERS
“Household Member” means a person who does not provide child care services who resides in the home facility
of a provider for 21 days or longer or who resides periodically throughout the year for a total of at least 21 days.
Household Member #1
I DO NOT have any household members
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(mm/dd/yyyy)
RELATIONSHIP TO YOU
Has this person lived out of state in the last 5 years?
Yes
No
Household Member #2
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(mm/dd/yyyy)
RELATIONSHIP TO YOU
Has this person lived out of state in the last 5 years?
Yes
No
Household Member #3
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(mm/dd/yyyy)
RELATIONSHIP TO YOU
Has this person lived out of state in the last 5 years?
Yes
No
Household Member #4
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(mm/dd/yyyy)
RELATIONSHIP TO YOU
Has this person lived out of state in the last 5 years?
Yes
No
Household Member #5
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(mm/dd/yyyy)
RELATIONSHIP TO YOU
Has this person lived out of state in the last 5 years?
Yes
No
See page 2 for EOE/ADA/LEP/GINA disclosures
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