Nebraska Amendment To An Application Change In Household Member - Dhhs Page 2
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1
2AMENDMENT TO AN APPLICATION
CHANGE IN HOUSEHOLD MEMBER
ADDITION/REMOVAL OF STAFF IN A FAMILY CHILD CARE HOME I OR II
PLEASE READ CAREFULLY, TYPE OR PRINT LEGIBLY
Name of Program: __________________________________________________________
License Number of Program: _______________
(Include FI, FII, CCC, SAOC, or PRE)
Phone Number: _____________Email Address: ___________________________________
Child Care Subsidy (choose one
): __Accept subsidy.
__Currently do not accept subsidy, but willing to in the future.
__Do not accept subsidy.
Provide the following information for ALL persons being added to the household INCLUDING
spouse, significant other, children (including a newborn), grandchildren, any other person, and for
any STAFF being added to/removed from a Family Child Care Home I or II.
LEGAL NAME
OTHER NAMES USED
SOCIAL SECURITY
BIRTH DATE
HOUSEHOLD MEMBER
STAFF
(Last, First, Middle Initial)
(maiden, alias, nickname )
NUMBER
(MM/DD/YY)
RELATIONSHIP TO
OR
APPLICANT
VOLUNTEER
(i.e., son, daughter, spouse )
CERTIFICATION AND SIGNATURES OF OWNERS
An Amendment to an Application must be signed by:
The owner, when the applicant is an Individual Owner;
All owners, when the applicants are a Partnership;
Two members, when the applicant is a Limited Liability Company(One signature will be accepted if
the LLC is a one member company.)
Two officers that have authority to bind the Corporation to the terms of the application, when the
applicant is a corporation. However, one signature will be accepted if the articles of incorporation are
submitted with the application.
I/We have fully disclosed all owners of the program regardless of whether an owner particpates in the operation
of the program. I/We certify to the best of my/our knowledge that the information provided on this Amendment
to an Application is true and correct.
______________________________________
_______________________________
________________
Print Name and Title
Signature
Date
____________________________________
_______________________________
________________
Print Name and Title
Signature
Date
______________________________________
_______________________________
________________
Print Name and Title
Signature
Date
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