Follow the steps to fill out the Statement of Incapacity Form CD-9606 online.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. In Part I, enter the name of the parent or caretaker who is incapacitated. Sign and date the form where indicated.
3. List the first names and ages of the child(ren) for whom financial assistance is being requested.
4. Provide the agency name and the authorized agency representative’s details, including their printed name and telephone number.
5. In Part II, the licensed health professional must indicate whether the incapacitated parent has a physical or mental health condition that affects their ability to care for the child(ren).
6. Enter the probable dates of incapacity by specifying the start and end dates.
7. Indicate the times of day the parent is unable to provide care for the child(ren) on the specified days of the week.
8. If applicable, fill in the extent of incapacity regarding the parent's physical or medical condition.
9. The licensed health professional must sign and date the form, providing their license type, license number, and the organization they are affiliated with.
10. Once all sections are completed, save your changes, and choose to download, print, or share the form as required.

Complete your forms online today to ensure timely processing of your child care assistance.