DEPARTMENT OF SOCIAL SERVICES (DSS) CHILD CARE SCHEDULE VERIFICATION FORM
DSS Worker Name	E-Mail Address
Telephone Number	Fax Number
The below individual (Client) has applied for child care assistance through the Department of Social Services. To process the application, this DSS must verify the Client’s work, education, or training schedule, as applicable.
Client Name	Client’s DCN
Please provide the information requested below for the named Client within 10 business days. Return this form to the Client to return to the DSS Worker or fax it or e-mail it as a scanned document to the DSS Worker using the information given above. If you have questions, please call the DSS Worker at the telephone number shown above.
Employer or Educational/Training Facility Name	Date Client Began Working or Attending
Physical Address of Employer or Educational/Training Facility (Street Address, City, State, ZIP Code)
Mailing Address of Employer or Educational/Training Facility, if different
Schedule Information
Indicate the days and hours the Client works or attends school or training. Be specific and indicate a.m. and p.m. (for example, 8:30 a.m. – 5:30 p.m.)
SCHEDULE	SUN	MON	TUE	WED	THU	FRI	SAT
Start Time
End Time
Is this individual subject to call in and/or overtime? Yes No
If the Client’s schedule varies, please provide an explanation.
Thank you for completing this form.
Printed Name of Person Completing Form	Title
Signature of Person Completing Form	Date
Telephone Number	E-Mail Address
INSTRUCTIONS DEPARTMENT OF SOCIAL SERVICES (DSS) CHILD CARE SCHEDULE VERIFICATION REQUEST FORM
DSS WORKER: Enter your name, e-mail address, telephone number, and fax number in the appropriate fields. Enter the Client’s Name.
CLIENT: Take the Child Care Schedule Verification Request Form to your job, school, or training location that has the authority to verify your schedule. Ask the person that has the authority to do so to complete the form and either fax or e-mail it as a scanned document or return it to you to return to the DSS office.
INDIVIDUAL COMPLETING FORM: The individual identified as the “Client” on this form has applied for child care assistance through the Department of Social Services (DSS). To process the application, the DSS must verify the individual’s employment, school, or training schedule. Enter the name of the employer at which the Client works or educational or training facility the Client attends. Enter the date the Client began working at this company or attending this educational or training facility. Enter the physical address and mailing address (if different), including the city, state, and ZIP code, of the employer, educational institution, or training facility. Record the Client’s work, school, or training schedule by entering the start and end time of each work shift or class/training session for each day of the week the Client is scheduled to work or attend class or training. Mark ‘Yes’ or ‘No’ to indicate whether the Client is subject to call-in or overtime. If the Client’s schedule varies on a regular basis, that is, it does not normally follow a regular pattern over an extended period of time, please explain why. Print your name and enter your title. Sign and date the form and include a phone number and e-mail address where the DSS Worker may contact you if there are questions regarding the information you provide. If you have questions, please contact the DSS Worker indicated at the top of the form.
Thank you for completing the Child Care Schedule Verification Form!