"Application for a Family Child Care Home I License" - Nebraska

Application for a Family Child Care Home I License is a legal document that was released by the Nebraska Department of Health and Human Services - a government authority operating within Nebraska.

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INSTRUCTIONS
Application for a Family Child Care Home I License
PROGRAM INFORMATION
1. Type of License: Indicate whether you are applying for a Provisional License (first year of licensure) or are
applying for a Non-Expiring Operating License (you must have first completed one year under a provisional
license.
2. Name of Family Child Care Program: The name of your program which will appear on your license.
3. Physical Address of Family Child Care Program: The physical address must be your residence.
4. Phone/Fax Number: The phone number with the area code for the family child care program. You are required
to have an operating phone on the premises. A cell phone is acceptable. A fax number is requested, if available.
5. Email Address: The email address of the family child care, where correspondence from the Department of
Health and Human Services can be sent.
6. Name of Primary Provider: The name of the individual who will responsible for the day to day operation of
the Family Child Care Home I program including compliance with all regulations.
7. Requested License Capacity: Refer to the Family Child Care Home I Regulations to determine the capacity
of your program. The capacity you request may not be approved by DHHS and/or the Fire Marshal. The
number of children in care cannot exceed the licensed capacity at any time.
8. Age Range of Children to be Served by Program: Refer to the Family Child Care Home I Regulations to
determine what age range of children you may serve (The most common range is 6 weeks to 13 years).
9. Hours of Operation: The hours that child care will be provided. Any hours between 9:00 pm and 6:00 am are
considered overnight care. Please refer to Family Child Care Home I Regulations regarding overnight care.
10. Days of Operation: Check each day of the week you will be operating your program.
11. Preferred Mailing Address: The address where all mail from the Department of Health and Human Services
should be sent. Include Street, P.O. Box (if applicable), city, state, & zip code.
12. Child Care Subsidy: Indicate whether you: Accept child care subsidy; Currently do not accept subsidy, but
willing to in the future; or Do not accept subsidy.
13. You must provide the required information for ALL persons residing in the household. NOTE: Applicant
must submit zoning approval from relevant jurisdiction, to the Department of Health and Human Services to
meet licensing requirements--- Refer to document “Additional Documentation Required.”
14. You must provide the required information for ALL persons who are designated as staff, substitutes, volunteers,
including YOURSELF.
Instructions continue on next page→→→→→
FCCH I
INSTRUCTIONS
Application for a Family Child Care Home I License
PROGRAM INFORMATION
1. Type of License: Indicate whether you are applying for a Provisional License (first year of licensure) or are
applying for a Non-Expiring Operating License (you must have first completed one year under a provisional
license.
2. Name of Family Child Care Program: The name of your program which will appear on your license.
3. Physical Address of Family Child Care Program: The physical address must be your residence.
4. Phone/Fax Number: The phone number with the area code for the family child care program. You are required
to have an operating phone on the premises. A cell phone is acceptable. A fax number is requested, if available.
5. Email Address: The email address of the family child care, where correspondence from the Department of
Health and Human Services can be sent.
6. Name of Primary Provider: The name of the individual who will responsible for the day to day operation of
the Family Child Care Home I program including compliance with all regulations.
7. Requested License Capacity: Refer to the Family Child Care Home I Regulations to determine the capacity
of your program. The capacity you request may not be approved by DHHS and/or the Fire Marshal. The
number of children in care cannot exceed the licensed capacity at any time.
8. Age Range of Children to be Served by Program: Refer to the Family Child Care Home I Regulations to
determine what age range of children you may serve (The most common range is 6 weeks to 13 years).
9. Hours of Operation: The hours that child care will be provided. Any hours between 9:00 pm and 6:00 am are
considered overnight care. Please refer to Family Child Care Home I Regulations regarding overnight care.
10. Days of Operation: Check each day of the week you will be operating your program.
11. Preferred Mailing Address: The address where all mail from the Department of Health and Human Services
should be sent. Include Street, P.O. Box (if applicable), city, state, & zip code.
12. Child Care Subsidy: Indicate whether you: Accept child care subsidy; Currently do not accept subsidy, but
willing to in the future; or Do not accept subsidy.
13. You must provide the required information for ALL persons residing in the household. NOTE: Applicant
must submit zoning approval from relevant jurisdiction, to the Department of Health and Human Services to
meet licensing requirements--- Refer to document “Additional Documentation Required.”
14. You must provide the required information for ALL persons who are designated as staff, substitutes, volunteers,
including YOURSELF.
Instructions continue on next page→→→→→
FCCH I
OWNERSHIP INFORMATION AND REQUIREMENTS
1. Business Ownership: Check the appropriate box.
2. Business Ownership Name: Enter the information listed below, associated with the box checked in number 1.
Individual(s), enter your legal name(s): Last, First, Middle Initial
Partnership, enter ALL partners legal names: Last, First, Middle Initial
Limited Liability Company (LLC), enter the legal name of the LLC.
Corporation, enter the legal name of the corporation
3. Authorized Agent(s): The full legal name and title of person(s) designated by the Business Ownership to sign
Amendment Applications and other Licensing Documents.
4. Federal Identification Number: If no Federal ID Number, indicate “none.” The number will not be used
without consent except as required by law.
5. Secretary of State Number: If you are a Limited Liability Company or Corporation, you must apply to the
Nebraska Secretary of State for this number.
6. Mailing Address IF different than in #11 on Page 1: Indicate the mailing address if it is different than in
#11 on Page 1. When both addresses are the same, indicate “same.”
7. Preferred Phone Number if different than in 4 on Page 1: Enter the phone number if different than in #4
on Page 1. When both phone numbers are the same, indicate “same.”
8. Preferred Email Address if different than in #5 on Page 1: Enter the email address if different than in #5
on Page 1. When both email addresses are the same, indicate “same.”
9. Has any entity identified as a Business Owner, or a member of an LLC or Corporation, listed in Item #2
on Page 2, ever applied for and received a child care/preschool license in Nebraska?: Individual Owner(s),
Partners, members of Limited Liability Companies and members of Corporations must report any previous
child care/preschool license history. This information is subject to verification.
10. If the Program is owned by an Individual Owner or Partnership Owner each owner must complete the
following: Each individual or partner must complete the LEGAL ATTESTATION on Page 3 of this
application to comply with Nebraska Revised Statutes 4-808 to 4-414 attesting to his/her lawful presence in the
United States. If more space is required to list Individuals/Partners, please add additional pages.
IF Program is owned by a Limited Liability Company or Corporation, continue to Certification and
Signature of Owner Section on Page 4: Read and complete the “Certification and Signature of Owners”
Section.
CERTIFICATIONS AND SIGNATURES OF OWNERS
Please read this section carefully before signing to ensure it is signed by ALL required parties.
Signing this application verifies that information provided is true and correct.
SUBMITTING APPLICATION, DOCUMENTATION, & FEES
OPTION 1: EMAIL: The completed application and the required additional documentation ONLY may be submitted to the Department by
scanning and emailing those documents to DHHS.ChildCareLicensing@nebraska.gov.
The required fee must be mailed separately via U.S. Mail, along with a copy of the front page of the application to the
appropriate address listed below in Option 2.
U.S. Mail
OPTION 2:
: The completed application, required additional documentation and fee may be mailed to:
Cass, Douglas, Sarpy & Washington Counties:
ALL Other Nebraska Counties:
DHHS/Division of Public Health
DHHS/Division of Public Health
Office of Children’s Services Licensing
Office of Children’s Services Licensing
rd
1313 Farnam Street, 3
Floor
P.O. Box 94986
Omaha, NE 68102
Lincoln, NE 68509-4986
FCCH I
FOR OFFICE USEONLY
Check/Money Order
#_____________________
APPLICATION FAMILY CHILD CARE HOME I
PLEASE READ CAREFULLY, TYPE OR PRINT LEGIBLY
PROGRAM INFORMATION
1.
Type of License: (Check one) __Provisional __Operating - Current License Number: __________
2.
Name of Family Child Care Program:___________________________________________________________________
3.
Physical Address of Family Child Care Program___________________________________________________________
(
County:______________________
Street, City, Zip Code)
4.
Phone/Fax Number, including area code: ______-______-_______Fax Number: ______-______-_______
5.
Email Address: ___________________________________________________________________________________
6.
Name of Primary Provider:_________________________________________________________________
7.
Requested License Capacity:________
8.
Age Range of Children to be Served: FROM: _______________ TO: _______________
Circle one (weeks, months, years)
Circle one ( months, years)
9.
Hours of Operation: (Specify a.m. or p.m.) FROM: _________ TO: _________ OR __24 Hour Care
10.
Days of Operation:(Check all that apply):__
Monday__Tuesday__Wednesday__Thursday__Friday__Saturday__Sunday
11.
Preferred Mailing Address:_________________________________________________________________
(
)
P.O. Box, Street, City, State, Zip Code
12
. Child Care Subsidy (choose one): __Accept subsidy.
__Currently do not accept subsidy, but willing to in the future.
__Do not accept subsidy.
13. Provide the following information for ALL persons residing at the Family Child Care Home I address INCLUDING
yourself, spouse, significant other, children, grandchildren, any other person.
LEGAL NAME
OTHER NAMES USED
SOCIAL SECURITY
BIRTH DATE
RELATIONSHIP TO
(Last, First, Middle Initial)
(maiden, alias, nickname )
NUMBER
(MM/DD/YY)
APPLICANT
(i.e., son, daughter)
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FCCH I
14. Provide the following information for ALL persons who are designated as staff, subsitutes, volunteers , including
YOURSELF:
LEGAL NAME
OTHER NAMES USED
SOCIAL SECURITY
BIRTH DATE
POSITION
PTE
WORK
(Last, First, Middle Initial)
(maiden, alias, nickname)
NUMBER
(MM/DD/YY)
(i.e., staff)
FTE
SCHEDULE
(hours/days)
OWNERSHIP INFORMATION AND REQUIREMENTS
1. Business Ownership:
__Individual__Partnership__Limited Liability Company__Corporation
(Check one)
2. Business Ownership Name:_______________________________________________________________
_______________________________________________________________
3. Authorized Agent(s):____________________________________________________________________
4. Federal Identification Number:_________________________
5. Secretary of State Number:____________________
(Limited Liability Company or Corporation ONLY)
6. Mailing Address IF different than in # 11 on Page 1:____________________________________________
______________________________________________________________________________________
7. Preferred Phone Number IF different than # 5 on Page 1: _______-______-_______
8. Preferred Email Address IF different than # 6 on Page 1:________________________________________
9. Has any entity identified as a Program Owner in Item #2 above ever applied for and received a child
care/preschool license in Nebraska? __YES __NO IF Yes, Identify the individuals and the name and
address of EACH Program: _________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________
10. IF the Program is owned by an INDIVIDUAL OR PARTNERSHIP each owner must complete the following
Legal Attestation section on Page 3 of this application: (If more than 3 partners, please add additional pages.)
→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→→
IF Program is owned by a LIMITED LIABILITY COMPANY OR CORPORATION continue to
Certification and Signature of Owner(s) Section on Page 4. →→→→→→→→→→→→→→→→→→
Page 2 of 4
FCCH I
LEGAL ATTESTATION
THIS PAGE TO BE COMPLETED ONLY IF THE PROGRAM IS OWNED BY AN INDIVIDUAL OR PARTNERSHIP
INDIVIDUAL OWNER/PARTNER #1
Legal Name:_______________________________Social Security Number:_________________________
Check one: __a. I am a citizen of the United States; OR
__b. I am qualified alien under the Federal Immigration and Nationality Act. My
Immigrant status and alien number is:____________________________________
If you checked box b above you must check the box of the document you are providing to verify
your lawful presence in the United States:
__An Alien Registration Receipt Card (Form I-551, otherwise known as a “Green Card”)
__An unexpired foreign passport with an unexpired Temporary I-551 Stamp bearing the same
name as the passport
__A document showing an Alien Registration Number (A#)
__A form I-94 (Arrival-Departure Record)
Signature: _______________________________________________________________ Date:__________________________
INDIVIDUAL OWNER/PARTNER #2
Legal Name:_______________________________Social Security Number:_________________________
Check one: __a. I am a citizen of the United States; OR
__b. I am qualified alien under the Federal Immigration and Nationality Act. My
Immigrant status and alien number is:____________________________________
If you checked box b above you must check the box of the document you are providing to verify
your lawful presence in the United States:
__An Alien Registration Receipt Card (Form I-551, otherwise known as a “Green Card”)
__An unexpired foreign passport with an unexpired Temporary I-551 Stamp bearing the same
name as the passport
__A document showing an Alien Registration Number (A#)
__A form I-94 (Arrival-Departure Record)
Signature:_ _______________________________________________________________ Date:_______________________
INDIVIDUAL OWNER/PARTNER #3
Legal Name:_______________________________Social Security Number:_________________________
Check one: __a. I am a citizen of the United States; OR
__b. I am qualified alien under the Federal Immigration and Nationality Act. My
Immigrant status and alien number is:_____________________________________________________
If you checked box b above you must check the box of the document you are providing to verify
your lawful presence in the United States:
__An Alien Registration Receipt Card (Form I-551, otherwise known as a “Green Card”)
__An unexpired foreign passport with an unexpired Temporary I-551 Stamp bearing the same
name as the passport
__A document showing an Alien Registration Number (A#)
__A form I-94 (Arrival-Departure Record)
Signature: _______________________________________________________________Date:_______________________
Page 3 of 4
FCCH I
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