To submit this form, you can either scan and email the completed application and required documentation to DHHS.ChildCareLicensing@nebraska.gov, or mail them to the appropriate address based on your county. For Cass, Douglas, Sarpy & Washington Counties, mail to DHHS/Division of Public Health, Office of Children's Services Licensing, 1313 Farnam Street, 3rd Floor, Omaha, NE 68102. For all other Nebraska Counties, mail to DHHS/Division of Public Health, Office of Children's Services Licensing, P.O. Box 94986, Lincoln, NE 68509-4986. Make sure all required forms and documents are included before submission.

There are no specific important dates for this form in 2024 and 2025. However, it is crucial to submit the amended application as soon as changes occur to ensure compliance with licensing regulations.

The purpose of the Amendment to an Application form is to allow child care providers and program administrators to update their licensing information. This can include changes such as new locations, directors, or business ownership. The form ensures that all details are current, maintaining compliance with state regulations and providing accurate information for the Office of Children's Services Licensing.

• 1. Name of Program: Enter the complete name of the child care program as it appears on the current license.
• 2. License Number of Program: Provide the license number for the program, including the prefix FI, FII, CCC, SAOC, or PRE.
• 3. Phone Number: Include the contact phone number for the program.
• 4. Email Address: Provide the email address associated with the program.
• 5. Child Care Subsidy: Indicate whether the program accepts, does not accept, or is willing to accept child care subsidies in the future.
• 6. Location: Include the physical address of the new location, county, planned occupancy date, and required documentation such as sketches, zoning approval, and liability insurance.
• 7. Building/Space Usage: Specify the date the space will be available for usage and provide a sketch or blueprint of the facility.
• 8. Licensed Capacity: Indicate the requested number of children and days of operation.
• 9. Hours of Operation: Specify the new hours of operation, including whether the program offers 24-hour care.
• 10. Age Range of Children to be served: Provide the age range of children the program will serve, expressed in weeks, months, or years.
• 11. Change in Business Ownership: Include the new ownership type, names of new partners or owners, and required documentation such as central registry checks and statements of agreement.
• 12. Program Name: Provide the new name of the program, licensee, and preferred mailing address.
• 13. Director: Submit information and documentation for the new director, including central registry checks, orientation review, law enforcement contact, criminal history checks, qualifications, and training completion.
• 14. Certification and Signatures of Owners: Obtain signatures from the owner, partners, or members with authority to bind the application, certifying the accuracy of the provided information.

Failure to submit this form can result in non-compliance with state regulations and potential penalties.

• Non-Compliance: Your program may be considered non-compliant with state regulations, which could affect its licensing status.
• Penalties: Failure to update the necessary information could result in fines or other penalties.
• Operational Disruptions: Your program may face operational disruptions if the changes are not officially recognized and approved.

• 1. Location Change: If your program is moving to a new location.
• 2. Director Change: When a new director is appointed.
• 3. Ownership Change: If there is a change in business ownership.
• 4. Capacity Change: To update the number of children the program is licensed to serve.
• 5. Subsidy Status Change: When there is a change in the program's child care subsidy status.