Who should use this form

Providers who are registered with the Child Care Assistance Program (CCAP).

When to use this form

Use this form to report changes to the child care assistance agency such as changes in:

•  Address

•  Rates

•  Contacts

What is the CCAP agency?

A family’s county or tribal social services agency is responsible for administering the Child Care Assistance Program and registering providers. In some cases, the social services agency may contract with another local agency to provide child care assistance. We call the agency that is administering child care assistance for the family as the agency.

If you are registered with more than one agency, provide a copy to each agency.

When this form should not be used

This change form cannot be used if you are experiencing any of the following changes:

•   You have opened an additional location. All            individually licensed sites or certified license     exempt sites must be registered separately.

•  You have changed licensing status. For example,     when a legal nonlicensed provider becomes a     licensed family child care provider.

•  Your site has completely changed family child care     license holders or a licensed or certified license     exempt center has changed ownership/controlling      individuals.

A new provider registration form must be completed when these situations occur. You may or may not be assigned a new provider ID.

If you have become accredited or received an early childhood credential and are requesting a higher rate for quality, complete the Quality Differential Rate Request Form (DHS-4795).

How to use this form

1.       Complete the Current provider information.

2.       Complete the sections in Changes to provider                    registration that apply to your program.

3.       Send the completed form to all agencies where                you are registered.

Please indicate what information has changed since your last registration.

List your new address.

Tell us where you want us to send written notices (check one option for each notice type):

a. Eligibility notices – These notices tell you about changes in your program's eligibility for child care assistance.

b. Service authorizations – These notices tell you about care authorized for each child at your program.

c. Billing forms – You submit one form per family, per billing period in order to get paid by child care assistance.

d. Remittance Advice for Electronic Fund Transfer (EFT) – These notices give details about each payment you receive via direct deposit      (EFT).

e. Payments/warrant remittance advice – These notices give details about each payment you receive via check/warrant.

If this change is due to a change in ownership, a new registration form must be completed.

Provide a copy of your updated license reflecting these changes.

If this change is due to a change in ownership or change in license type (from family child care to licensed center care), a new registration form must be completed.

Provide a copy of your updated certification reflecting these changes.

If this change is due to a change in ownership or certified/license status (from a certified license exempt center to a licensed child care center), a new registration form must be completed.

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Start
End

Rate

Infant

Toddler

Pre-school

Kindergarten 

School age

Hourly rate

Daily rate

Weekly rate

Other rates

Other rates

Attach any changed written payment policies.

*Note: You must submit a

To report a new site contact or payment contact. For a name change only, see Provider or contact name change.

Site contact

Payment contact

To report when the current provider or contact has changed their name. Do not use this section to report a new provider or contact. To report a new contact see Contacts. Licensed providers should also report name changes to their licensor.

Previous name

New name

Name

Date of birth

Licensed family child care providers must report new household members to their licensor.

Change authorization

Penalty warning

If you get child care assistance benefits, you must follow these rules. Do not give false information or hide information:

•  To get or continue to get child care assistance benefits

•  To help someone else to get or continue to get child care assistance payments. The state may bar a provider who breaks either of these rules or who repeatedly and/or intentionally violates program laws under M.S. 119B or M.S. 245E. The bar lasts three years for the first fraud and is permanent for the second fraud. The bar may affect your ability to clear a background study, hold a child care license or certification, have direct contact or access to children in a child care setting, and/or participate in other Department of Human Services programs.

A person who supplies false information in order for them or someone else to receive child care assistance may also be prosecuted criminally.

Acknowledgement

By signing and dating below:

•  If I am a licensed provider: 

◦ I attest and represent that I am an owner, license holder, or controlling individual as defined in M.S. 245A.02, and I am fully               authorized  to sign this document to bind myself and all other owners, license holders, and controlling individuals to the terms of       this agreement.

◦ I understand and agree that by signing this document I am representing to the government that all of the information provided,     including my signature, are true and accurate and that any misrepresentations or failure to provide accurate information can result in     possible administrative, civil and criminal sanctions to me, as well as the owners, license holders, controlling individuals and/or the     provider/entity.

•  If I am not a licensed provider:

◦ I understand and agree that by signing this document I am representing to the government that all of the information provided,   including my signature, are true and accurate and that any misrepresentations or failure to provide accurate information can result in     possible administrative, civil and criminal sanctions.