Fillable CHILD CARE AWARE of AMERICA MILITARY FEE ASSISTANCE (Child Care Aware)

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CHILD CARE AWARE of AMERICA MILITARY FEE ASSISTANCE (Child Care Aware)

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CHILD CARE AWARE® of AMERICA MILITARY FEE ASSISTANCE
PROVIDER CHANGE REQUEST FORM
REASON FOR CHANGE OF PROVIDER (PLEASE SELECT ALL THAT APPLY)
Permanent Change of Station
Change Of Home Address Due To A Recent InState Move
New Provider Closer To Sponsor/Spouse Place Of Employment
New Provider Has Space Available For Each Child In The Family
Unsatisfied With Previous Childcare Provider/Previous Provider Closed Down
New Provider Meets High Quality Accredited Child&are Standards
CHILD CARE AWARE® Of AMERICA Military )HH$VVLVWDQFH Requires Notification Fifteen
'ays Prior To Ending Child Care Services, regardless of who initiates the termination. When
FDUHPust be terminated sooner, please contact CHILD CARE AWARE® of AMERICA
0LOLWDU\3rogram immediately. For assistance in completing this form, please call 1-800-793-0324.
Services Received Prior To The Completion And Approval Of The Change Of Provider Request
Will Not Be Reimbursed. Reimbursements will begin once CHILD CARE AWARE® of AMERICA
Military Program receives and approves all required forms and supporting documents. This
includes confirming the new provider qualifications and rates and finalizing reimbursements to
the former provider.
If The New Provider Does Not Meet The Eligibility Requirements Of Your Designated Fee
Assistance Program (OMCC or MCCYN), Then You (The Sponsor) Are Responsible For Child
Care Fees Incurred Until You Secure An Eligible Provider.
A Completed Provider Fee Assistance Application must be submitted, along with all UHTXLUHG
supporting documents for the new providerEHIRUH&+,/'&$5($:$5(RI$0(5,&$ZLOO
LVVXHUHLPEXUVHPHQWV
TODAY’S DATE:
SPONSOR INFORMATION:
Family Identification Number:
Name:
Sponsor/Spouse Phone Number: __________________________
Address:
City: ___________________ State: _____________ Zip Code: ________________
Check If New Address/Phone Number
CHANGE OF PROVIDER APPLIES TO FOLLOWING CHILD(REN):
Child’s Name: Date of Birth
FORMER PROVIDER INFORMATION: NEW PROVIDER INFORMATION:
Name: Name:
Address: Address:
City: State: _____Zip Code: City: State: ______Zip Code:
LAST DAY OF CARE: FIRST DAY OF CARE:
NEW PROVIDER SCHEDULE OF CARE INFORMATION: (Please identify the days and hours a week each child will
need child care)
Name of Child Days Child Is In Care (Check all that apply)
SUN MON TUE WED THU FRI SAT
Hours Child Is In Care
From To
1.
2.
3.
4.
Please Fax or Email to:
CHILD CARE AWARE® of AMERICA
1515 N. Courthouse Rd, 2
nd
Floor
Arlington, VA 22201
Fax: (703) 341-4103
msp@usa.childcareaware.org
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CHILD CARE AWARE of AMERICA MILITARY FEE ASSISTANCE (Child Care Aware)

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Completed 20 January 2021

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