DECCD Parent Change of Info Form

DECCD Parent Change of Info Form

IMPORTANT! Please DO NOT upload Application Documents or Change of Provider documents to this form.

Do not upload Parent Application Documents, Redetermination Application Documents, Add A Child Documents or Change of Provider Forms to this form. Uploading application forms to this form will cause major delay with your application. To access the web form for Application documents, please click the Parent Document Upload link: https://www.apps.mdhs.ms.gov/ccis/NewApplication/AppStartPage.aspx

This is NOT the Online Redetermination Link

If you are up for Redetermination and your Deadline has not passed, please submit your Online Redetermination through this link >>> https://www.apps.mdhs.ms.gov/ccis/NewApplication/AppStartPage.aspx

Parent Name*

Please enter your first and last name as it appears on your account.

DOB*

Social Security Number*

Please input the last four digits of your social security number. (Ex.xxx-xx-1234)

Current Address*

Ex. 750 N State St. Jackson, MS 39209

Current Phone Number*

Ex. (000) 123-4567

Current Email Address*

County*

Please list the MS county or put "Out of State." The counties are available on the dropdown menu.

Select or enter value

Change of Address

ALL DOCUMENTS can be either FAXED, EMAILED, POSTAL MAIL to DECCD or UPLOADED to this form. Details will be provided at the end of this form.

Did your address change?*

If Yes, Please enter the type of Address change. IMPORTANT: If your physical address changed, You MUST submit one of the following documents: a valid Mississippi driver's license with the same address as the physical address that you are changing to, valid state issued identification with the same address as the physical address that you are changing to, current bank statement, current cell phone bill, current utility bill, current cable bill, current employment records, a rent or lease agreement effective as of the date the document is submitted to MDHS with the signature page, or a MDHS Transitional Living Form.

Physical Address Only

Mailing Address Only

Both Addresses Changed

No Change in Address

New Address Line 1

Suite/ Apt/ Lot #

City

State

Zipcode

Date of Address Change

Change of Household Size

ALL DOCUMENTS can be either FAXED, POSTAL MAIL to DECCD or UPLOADED to this form. Details will be provided at the end of this form.

Change in Household Size*

Yes

New Relationship Status

Marriage (Please submit a valid copy of your Marriage License and Employment Income/School Enrollment Information)

Child's Biological Parent Lives In Home (Please submit Employment Income/School Enrollment Information)

Divorce (Please submit a valid copy of your Divorce Decree)

New Child (See information below)

Child's Biologiocal Parent No Longer in the Home

Any NEW CHILD must be added through the Application link on our website. https://www.apps.mdhs.ms.gov/ccis/NewApplication/AppStartPage.aspx

Child's Full Name

Please submit a copy of the child's Long-Form Birth Certificate

Child's Date of Birth

Employment Change

ALL DOCUMENTS can be either FAXED, POSTAL MAIL to DECCD or UPLOADED to this form. Details will be provided at the end of this form.

Did your Employment Status Change?*

Yes

Date Change is Effective

Employment Status

If NO LONGER EMPLOYED: ~A 90 Day Job Search Period may be given to allow you to search for a NEW JOB, IF job loss is reported within 10 days of loss. ~ If you become employed during the 90 day Job Search Period, You must submit your TWO most recent check stubs (Bi-weekly Pay), FOUR most recent check stubs (Weekly Pay) or Most recent check stub (Monthly Pay) OR a notarized letter on company letter head from your new employer indicating your RATE of Pay, HOW OFTEN you are paid, HOW MANY HOURS per week you work, and your DATE OF EMPLOYMENT. ~ Failure to submit the documents before the end of the 90 Day Job Search Period will cause your certificates to terminate immediately and you will have to REAPPLY.

If you have changed to a Full Time Student, we will need you to submit your School Enrollment Verification stating that your a Full Time student for the current semester. No change to your priority population will be made without the submission of this information. It must show Full Time status before we can take it into effect.

Employed

No Longer Employed

Full Time Student

Work Hours And/Or Pay Rate Has CHANGED

IF YES: Please submit your most recent check stub for Monthly pay, TWO most recent check stubs for Bi-weekly/Semi-monthly pay, FOUR most recent check stubs for Weekly pay OR a notarized letter on company letter head from your new employer indicating RATE of pay, HOW OFTEN you are paid, HOW MANY HOURS per week you work, and your DATE OF EMPLOYMENT. The co-pay will not change if the new income documents submitted do not meet the work hour requirement.

Yes

New Work Hours Per Week

New Rate of Pay

Changed Employers

Yes

New Employer

Change of Parent Name

ALL DOCUMENTS can be either FAXED, POSTAL MAIL to DECCD or UPLOADED to this form. Details will be provided at the end of this form.

Did your name change legally?

If YES, Please submit a valid driver's license, government issued ID or court document granting legal name change.

Select or enter value

New Parent Name

(First Middle Last) Please enter your new name exactly as it appears on your new ID.

Did your child's name change legally?

If YES, Please submit a valid driver's license, government issued ID or court document granting legal name change.

Yes

Previous Child Name

(First Middle Last) Please enter your old child's name exactly as it appeared on your account.

New Child Name

(First Middle Last) Please enter your child's new name exactly as it appears on their new ID.

Ending Certificate Services

Do you wish to end childcare certificate services?

By ending your certificate services for a child, you understand that if you should need a certificate in the future, you will need to REAPPLY for that child.

Which Child/ Children no longer need certificates?

Please list the name(s) of your child(ren) who no longer need childcare certificates.

Last Date of Usage

Documents can be sent to the following:

Fax Number: 601-359-4422

Mailing Address: DECCD P. O. Box 352 Jackson, MS 39205

File Attachments

If you would like to upload a copy of any document(s) that are required for the specific change you are trying to make, please upload the document(s) here. Legible Photos or scanned PDFs of required documentation is acceptable.

Drag and drop files here or

Parent Confirmation*

By checking this box, I certify that the information I have provided is true and correct. I certify that I have not omitted or misrepresented any information required for eligibility for the Mississippi Child Care Payment Program.

What are you trying to change?*

Send me a copy of my responses

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