CITC Child Care Assistance Program Quality Improvement Grant Request Form

CITC Child Care Assistance Program Quality Improvement Grant Request Form
Type of Grant requested
Health & Safety
Amount requesting
Educational
Amount requesting
Staff Development
Amount requesting
Provider Info
Contact Name*

First NameLast Name
Date*

MonthDayYear
Date
Provider/Facility Name
Phone Number
Email Address*
example@example.com
Provider Type

Licensed CenterLicensed HomeApprovedIn-Home
Describe in detail why you are requesting a grant and how it will be used:
Providers who fail to abide by any terms of this grant may be ineligible for future grants.

By signing this form, I certify that I have not received reimbursement or payment for these expenses from any other agency and I agree to a site visit. I understand that qualified expenses must be used only for the child care facility and no personal expenses are permitted. I understand that grants are awarded based on demonstrated need and availability of Quality Improvement funds. I also understand that I will be required to submit the original receipts within 30 days from receipt of a Quality Improvement Grant.

Unused or misspent funds must be returned to CITC, within TEN days of notice.
Written/Typed Provider Name*
Signature*

Clear
Date

MonthDayYear
Date
Upload the receipt if any.

Cancelof
Cook Inlet Tribal Council • Child Care Assistance Program • 3600 San Jeronimo Drive • Anchorage, AK 99508

Phone: (907) 793-3300 • Fax: (907) 793-3296 • Email: childcare@citci.org
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