Name and Telephone Number Address Who are you representing? 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Provider Name' in the designated field. This identifies the child care provider associated with the waiver request.
3. Next, input the 'Provider ID #' which is essential for tracking and processing your request.
4. Fill in the 'Mailing Address', ensuring that all components such as street address, city, state, and zip code are accurately completed.
5. In the 'Telephone' field, provide a contact number where you can be reached for any follow-up regarding your waiver request.
6. Complete the 'Email' section to facilitate electronic communication about your application status.
7. Select applicable 'Program Type' options by checking all that apply to your child care service.
8. For detailed explanations regarding your waiver request, utilize the provided sections to articulate your needs clearly. Attach additional pages if necessary.

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