Cleaning and Supplies for Child Care Providers (CSCP)
Self-Certification Form
Name of Facility or Provider:
Facility License Number (if applicable):
Number of Children Served in the Facility:
Address (where children served):
City/State/Zip:
Mailing Address (if different):
City/State/Zip:
Contact Name:
Main Contact Phone Number:
Email:
Provider Type
Center: Licensed License Exempt
Home Based: Licensed License Exempt
Certification
Receiving Both
I understand, as a provider, that this self-certification form is a requirement to receive
CSCP funds, supplies, or both to serve essential workers and/or at-risk populations
during the COVID-19 pandemic. As stated on this form, my program currently is open or
will be open by the date specified and the funds and/or supplies will be used solely for
these restricted purposes.
Signature of Licensee/Exempt Provider:
Today’s Date:
Date Received:
Date Verified by R&R Staff:
Amount Awarded:
Staff Signature:
Open date for COVID-19:
Planned reopen date (if temporarily closed due to COVID-19):
Receiving Funds
Receiving Supplies
click to sign
signature
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click to sign
signature
click to edit
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