Get Fcdjfs #1401-cc (6/09)

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

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editing tool.
2. 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.
3. Input the case number in the designated field.
4. Fill out the provider name and choose the appropriate options for household composition by checking either 'Initial,' 'Redetermination,' 'Change,' or 'Case Termination'.
5. Specify the requested start date of care using the provided fields for month, day, and year.
6. Enter the provider site or designation's first name and last name.
7. Input the provider vendor number and the social security number in their respective fields.
8. For the section on gender, select 'M' for male or 'F' for female according to the individual’s gender.
9. List the names of children in the household by filling in the fields for each child as appropriate (1st child, 2nd child, etc.).
10. In the comments section, provide any additional information or notes as needed.
11. Ensure the provider signature is affixed in ink to verify the accuracy of the information.
12. The parent or customer must sign in ink to acknowledge and authorize the information submitted.
13. Finally, review the completed form for accuracy, then save the changes, download, print, or share the form as required.

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