Nebraska Amendment To An Application Change In Household Member - Dhhs

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INSTRUCTIONS
Amendment to an Application FOR Change in Household Member
Addition/Removal of Staff in a Family Child Care Home I or II
Completing the Amendment to an Application:
 Enter the complete name of the program as it appears on the license.
 Enter the complete license number beginning with FI, FII, CCC, SAOC, or PRE.
 Child Care Subsidy: Indicate whether you: Accept child care subsidy; Currently do not
accept subsidy, but willing to in the future; or Do not accept subsidy.
 Instructional information is written in Italics beside or below the required information,
documentation or form to be submitted.
 ALL required parties must sign the Amendment to Application. Signing this Amendment to
Application verifies that information provided is true and correct.
Additional Forms/Paperwork Required:
As appropriate to age the following forms
must be submitted with the Amendment to an Application. Forms are located on the Forms Page of the
Nebraska Child Care Licensing Website found at the link:
 FORM – 13 years and older; Consent and Authorization for Release of Information for
the type of care you provide.
 FORM – 19 years and older; Consent and Authorization for Release of Information.
 FORM – 19 years and older; Report of Law Enforcement Contact.
 Criminal history record check from one or more City, County, and State Law
Enforcement Agencies based on the individuals residence – 19 years and older.
Submitting the Amendment to an Application and forms:
OPTION 1: EMAIL: The completed application and the required additional documentation may be
submitted to the Department by scanning and emailing those documents to
DHHS.ChildCareLicensing@nebraska.gov.
OPTION 2: U.S. Mail: The completed application and required additional documentation may be
mailed to:
Cass, Douglas, Sarpy & Washington Counties:
ALL Other Nebraska Counties:
DHHS/Division of Public Health
DHHS/Division of Public Health
Office of Children’s Services Licensing
Office of Children’s Services Licensing
rd
1313 Farnam Street, 3
Floor
P.O. Box 94986
Omaha, NE 68102
Lincoln, NE 68509-4986

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