Child Care Assistance Change Notification2

Child Care Assistance Change Notification

PRIM ID

Provider License Number (old one if number is changing)*

Email Address*

Submitter's Name*

First Last

What changes are needed?

New Email Address

New Phone Number*

New Mailing Address*

Street Address City ZIP Code

New Physical Address*

Street Address City ZIP Code

New Primary Contact Name*

First Last

New Primary person's title*

Operational Change Description: hours, days, age groups served*

Direct Deposit Change Description*

Rates Change Description*

New EIN Number*

New License Permit Number*

License Effective Date*

Start Date of Emergency Closer*

End Date of Emergency Closer*

Reason For Emergency Closer?*