ChildCareRequirementsToReport

Your Information

First Name *

Last Name *

Twist Number *

Call your child care provide if you aren't sure what this is.

Date of Birth *

Daytime Phone *

E-Mail Address *

Report Contact Change

Mailing Address

Physical Address

Phone Number

E-Mail Address

Report Change in Family Size

Household Membership

Report Change in Family Income

Income Change

Enter the information below to determine income change eligibility.

How Much Are You Paid?

How Often Are You Paid?

How Many People in Household?

Report Permanent Loss of Work, Training or Education

Last Day of Employment

Last Day of Attendance Training/Education

I understand that if I knowingly provide false information or fail to disclose a material fact to make myself appear eligible for child care services, I may have to repay the child care program for services received fraudulently, and criminal charges may be filed against me with the local prosecuting authority. By submitting this form, I understand that: (1) a person who obtains or attempts to obtain, by fraudulent means, services to which the person is not entitled may be prosecuted under applicable state and federal laws, (2) I am receiving services from Workforce Solutions Panhandle CCS and all information on this submission represents a complete and accurate statement of my household income; and family size at the time of submission.

Requirements to Report Form

Your Information

Report Contact Change

Report Change in Family Size

Report Change in Family Income

Report Permanent Loss of Work, Training or Education