Childcare Provider Change Request Form

Parent/Caretaker Name: _______________________ Caseworker:________________________

Social Security Number: _________________ Phone No.:____________ Email: _____________

Complete this form if you need to change your childcare provider.

Your co-pay must be paid in full with your current provider or your benefits may be subject

to termination. Please allow 10 days for processing.

Child Name /

Current

New Provider’s

Beginning Date

SSN

Provider’s Name

Name

ID Number

of Service

Parent/ Caretaker Signature: ___________________________________ Date: ______________

Childcare Information Line: 216.987.6929

Fax Number: 216. 987.8655

Cuyahoga Job and Family Services



1641 Payne Avenue, Cleveland, Ohio 44114



(216) 987-7000

Ohio Relay Service (TTY) 711

Our Mission:

To promote economic self-sufficiency and personal responsibility

for families by providing a broad range of quality services.

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Parent category: Business