For Families-Client Application Packet
Required Registration Forms
· Child Care Assistance Program Application (DHS-3550) It is IMPORTANT to submit ALL of the verifications indicated on the form and listed
on the back page. Keep the last 2 pages of Rights and Responsibilities for your records.
· Client Statement of Good Cause and Cooperation with Child Support Enforcement (DHS -2338) This form is required if there are
children in the household with an absent parent (parent not living with them), even if you already have an open child support case. If there are multiple
absent parents, a separate form to be completed for each.
· Referral to Support and Collections (DHS -3163B) This form is also required if there are children in the household with an absent parent, even
if you already have an open child support case. If there are multiple absent parents, a separate form to be completed for each.
· Employability Plan and Student Parent Agreement This form is required to be completed for parents that are attending college. This is not
needed for students attending High School or GED classes.
· Parent Acknowledgement when choosing an LNL provider (DHS-5367) This form is only required if you are choosing to use a non-licensed
provider. This does not need to be completed and returned if your provider is licensed
The documents below are provided for your reference. They do not need to be returned.
· Do You Have a Disability? Pamphlet (DHS-4133) Explains the rights that people with disabilities have and the kind of help that is available
· Standard Maximum Rates (DHS-6441B) Lists the current child care rates that are reimbursable through CCAP
· Child Care Assistance Program Copayment Schedule (DHS-6413C) You may have to pay a portion of child care costs directly to your
provider. The schedule outlines what a bi-weekly co-payment would be based on a family’s income and size.
· Caring for children (DHS-4723) Helps parents in immigrant and refugee families find and use child care in Minnesota.
· Change Report Form (DHS-4794) You are required to report any changes that occur in your household to your child care case worker within 10
days of the change. This includes changes in the number of people living with you, your income, your address, your employment and/or school schedule.
· Redetermination Form (DHS-5274) Used to determine ongoing eligibility for households that are currently open on the Child Care Assistance
· Request for In-Home Care Form (DHS-6475) Form used if wanting child care to be done in the child’s home