Child Care Provider Request For Information
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1MISSOURI DEPARTMENT OF SOCIAL SERVICES
RESET
CHILD CARE PROVIDER REQUEST FOR INFORMATION
DVN:
Child Care Provider Registration Application FA350.
The items checked below must be returned in order to process the
Send the requested items no later than
.
CHILD CARE PROVIDER REGISTRATION APPLICATION AND
CHILD CARE VENDOR INVOICE
AGREEMENT (FA350)
Original Daily Attendance Records must be attached to invoice
Complete FA350, agreeing to the highlighted statements
Sign the invoice and/or the attendance records
Complete FA350, with provider and/or parent signature
Parent must sign/initial the attendance records
Legible copy of a photo ID
Complete the month/year on attendance records
Current TB test result
School age children must be signed in/out each time they
Copy of current child care license
enter or leave care
A local background screening from current state of residence
Complete the Daily Attendance Record
Call (877)862-2425 to make an appointment to be
Complete the Child Care Vendor Invoice
fingerprinted
Resolve discrepancies on the Child Care Vendor Invoice
Complete the attached Family Care Safety Registry Request
form for____________________________, or submit request
* The invoice does not match the submitted attendance
online at
https://webapp02.dhss.mo.gov/bsees/
.
records.
ACCREDITATION RATE ENHANCEMENT AGREEMENT
CHANGE OF ADDRESS
(CD149)
Complete the CD149, agreeing to the highlighted statements
Complete attached FA350 in full
Sign the Accreditation Rate Enhancement Agreement
Provide proof of address change (ex. copy of bill or lease
agreement, etc.)
Current copy of Accreditation Certificate
PROOF OF FEDERAL TAX ID
OTHER
Copy of social security card
Federal Tax Identification Number (EIN) on IRS letterhead
Acceptable forms of proof of your Tax ID include the
following:
* Copy of form 941 – Employer's Quarterly
Federal Tax Return with barcode, or
* Copy of form 8109 Federal Tax Deposit
Coupon, or
* Copy of letter 147c (this letter may be obtained
from IRS).
CONTRACT FOR PURCHASE OF CHILD CARE (CM-5)
Complete the Contract for Purchase of Child Care
Complete the contract with the provider signature and date
Complete the Contract with license begin and end dates.
The DHSS license is showing pending or closed. You cannot
Contract for Purchase of Child Care without a valid license.
PROVIDER RELATIONS REPRESENTATIVE
IF YOU HAVE ANY QUESTIONS OR NEED MORE
INFORMATION, CONTACT:
PHONE NUMBER
DATE
(
)
CD-148 (REV9/12)
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