Requirements to Report Form

Your Information

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

Report Contact Change

Report Change in Family Size

Report Change in Family Income

Enter the information below to determine income change eligibility.

Report Permanent Loss of Work, Training or 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.