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DCC – 108
(R. 10/2017)
922 KAR 2:260

COMMONWEALTH OF KENTUCKY
Cabinet for Health and Family Services
Department for Community Based Services
Division of Child Care

Notice of Adverse Action for Child Care Providers and Early Care and Education Professionals
Name____________________________________
License No.________________________________
Date_____________________________________

Registered Child Care Providers:
The following action has been taken which ends or prevents your ability to receive child care subsidy payments as a
registered child care provider.
Your application to be a registered child care provider is withdrawn.
This action is taken in accordance with the following administrative regulation or statute: ___________________.
Reason for the action: ______________________________________________________________. If you want
to reapply to become a registered child care provider in the future, you may do so at any time by contacting your
Service Agent.
Your application to b