Fillable Amendment To An Application Not Household Member

Amendment To An Application Not Household Member - Dhhs Page 2

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AMENDMENT TO AN APPLICATION

NOT INCLUDING HOUSEHOLD MEMBER

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.

Check the box in front of EACH of the item(s) which will be amended and submit the required additional

information, completed forms, and documentation listed beside or below each item in the section. All FORMS are

located on the Forms page of the Nebraska Child Care Licensing Website.

__ Location: (Submit the following information)

 Physical Address of New Location: ______________________________________________________

(Physical Stree Address)

________________________________________________________________________

(City)

(Zip Code)

(County)

 Planned occupancy date:______________

 A sketch, diagram, or blueprint of the facility showing the dimensions, arrangement of room to be used

by children, and outdoor play area.

 Copies of zoning approval from the relevant jurisdiction.

 Proof of Liability Insurance for new location.

 FORM - Agreement for Prior to Hire Registry Checks.

__ Building/Space Usage (not relocation): Explain:________________________________________________

 Date Space Available for Usage:___________________

 Sketch/Diagram or Blue Print of facility with dimensions. Indicate currently approved indoor/outdoor

licensed areas and identify new indoor/outdoor space.

__ Licensed Capacity:

 Requested number of children:________

__ Days of Operation:

(Circle new days of operation) Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday

__ Hours of Operation

(

FROM_________ TO________ OR __ 24 Hour Care

New hours, specify a.m. or p.m

)

__ Age Range of Children to be served

FROM: _______________ TO: _______________

Circle one (weeks, months, years)

Circle one ( months, years)

__ Change in Business Ownership

: (Circle new ownership type)

Individual / Partnership / Limited Liability Company / Corporation/

District (i.e., school) / Other (i.e., city, tribal)

 New Name of Partner/LLC/Corp_______________________________________________________

 FORM

–

Agreement for Prior to Hire Registry Checks

(Submit the form)

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Amendment To An Application Not Household Member - Dhhs Page 2

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