Learn about the Medicaid 1115 Transformation Waiver Renewal.
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Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
The applicant, designee or head of the governing body must complete and sign Form 2760, and enter the names of the controlling persons to include:
- Owner of the operation or member of the governing body of the operation, including, as applicable, an executive, an officer, a board member, a partner, a sole proprietor and the sole proprietor's spouse, or the primary caregiver at a child care home and the primary caregiver's spouse;
- Person who manages, administrates, or directs the operation or its governing body, including a day care director or a licensed administrator; or
- Person who either alone, or in connection with others, has the ability to influence or direct the management, expenditures or policies of the operation. For example, a person may have influence over the operation because of a personal, familial or other relationship with the governing body, manager or other controlling person of the operation.
A person does not have to be present at the operation or hold an official title at the operation or governing body in order to be a controlling person. An employee, lender, secured creditor or landlord of the operation is not a controlling person unless the person meets the definition as stated above.
When to Prepare
Complete, sign and submit this form when submitting an application to Child Care Licensing for a permit and within two days after a person becomes a controlling person at the operation.
Mail the completed form to the local Child Care Licensing office.
Do not leave any fields blank. Enter “none,” “not applicable” or “NA” if the item does not apply.
Operation Information – Enter the operation name and operation number (if already licensed, certified, registered or listed). The remaining operation information is self-explanatory.
Signature and Date – The applicant, designee, or head of the governing body must sign and date the form.
Applicant (Controlling Person) Information
Name – List every name used by this person, including a woman’s maiden name and previous married name(s). Enter the full middle name (do not use only the middle initial). Add additional pages, if necessary.
Address and Phone – Enter the personal mailing address and phone number for the person listed.
Title, Position or Relationship – Select the appropriate choice:
- Licensed Administrator refers to Licensed Child Care Administrators or Licensed Child Placing Administrators.
- Director refers to a:
- director of a child care center or licensed child care home;
- operation director of a before or after-school program or school-age program; or
- program director of a before or after-school program or school-age program.
- Primary Caregiver of a Child Care Home, Spouse of Primary Caregiver, and Adult Living in Child Care Home are terms only associated with licensed, registered or listed child care homes.
Effective Date of Title, Position or Relationship – Enter the date the person began the role of a controlling person.
Use the “Add Applicant” button to add additional controlling person(s) to the form. To delete, click on the “Remove Applicant” button.