Foster Relative Or Other Designated Caregiver Daycare Verifcation
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1
2Department of Family and Protective Services (DFPS)
Form 1809
Revised August 2013
F
/R
& O
D
C
D
V
OSTER
ELATIVE
THER
ESIGNATED
AREGIVER
AYCARE
ERIFICATION
CPS (DFPS)
Purpose: This form is required for foster parents, relatives and other designated caregivers requesting
day care.
Instructions: Complete all sections of the form.
Directions: Once signed, the original must be turned in to the caseworker processing your day care
request. Please contact your kinship or conservatorship caseworker if you have any questions.
I, ___________________________________________, am the caregiver for the following child(ren) in
Caregiver name-please print
(Circle one: foster parent
kinship caregiver)
DFPS conservatorship:
___________________________________
_________________________________
___________________________________
_________________________________
I have sought daycare services from the following the community resources:
Check all that apply:
□
□
Head Start Programs
Pre-kindergarten Program
□
□
Public School Early Education Programs
Other _______________________
Use back of the form if necessary
Please provide the following information:
Number of persons living in the home (excluding children in DFPS conservatorship): __________
Monthly Gross Family Income: (excluding income of children in DFPS conservatorship living in
your home): ________________see reversed side for additional instructions
The above information is true, correct and complete. I understand that giving false information to
DFPS is considered fraud.
__________________________________________
______________________________________
Caregiver Signature
Date
----------------------------------------------------------------------------------------------------------------------------- ---------------
For completion by CPS staff if waiver is granted
□
DFPS has waived completion of the above information based on the fact that verification
of this information would prevent an emergency placement that is in the child's best
interest.
________________________________________
______________________________________
Caseworker Signature
Date
Program Director Signature
Date
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