FCDJFS #1401CC (6/09)Type of Change:Child Care Center Change Request Case NameFirstMiddleStreet AddressCase Number CityProvider Name Household CompositionLast Initial Redetermination ChangeRequested.
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How to use or fill out the FCDJFS #1401-CC (6/09) online
This guide provides step-by-step instructions for users to effectively fill out the FCDJFS #1401-CC (6/09) online. By following these clear and accessible steps, users with varying levels of experience can ensure they complete the form accurately and efficiently.
Follow the steps to complete the FCDJFS #1401-CC (6/09) online
- Click the ‘Get Form’ button to obtain the form and open it in your preferred online editing tool.
- In the case name section, enter the first name, middle name, last name, street address, city, state, and zip code of the individual associated with the case.
- Input the case number in the designated field.
- Fill out the provider name and choose the appropriate options for household composition by checking either 'Initial,' 'Redetermination,' 'Change,' or 'Case Termination'.
- Specify the requested start date of care using the provided fields for month, day, and year.
- Enter the provider site or designation's first name and last name.
- Input the provider vendor number and the social security number in their respective fields.
- For the section on gender, select 'M' for male or 'F' for female according to the individual’s gender.
- List the names of children in the household by filling in the fields for each child as appropriate (1st child, 2nd child, etc.).
- In the comments section, provide any additional information or notes as needed.
- Ensure the provider signature is affixed in ink to verify the accuracy of the information.
- The parent or customer must sign in ink to acknowledge and authorize the information submitted.
- Finally, review the completed form for accuracy, then save the changes, download, print, or share the form as required.
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