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2. Date
   Date
4. Reporter's First Name
   (optional)
5. Reporter's Last Name
   (optional)
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Phone (optional)
17. Unlicensed Provider's First Name
    (if known)
18. Unlicensed Provider's Last Name
    (if known)
20. Address or identifying location information
    (of unlicensed provider)
22. City
23. State
24. Zip
26. Number of children in care:
27. Approximate ages:
28. Timeframe (days of week, hours):
30. How did you become aware of the situation?
32. What did you observe that led you to report? Safety concerns?
34. How long have you been aware of the situation?
36. A warning letter will be sent to this person. If after 2-3 months you believe that this person is continuing to do unlicensed care, please notify Anoka County Child Care Licensing at 763-324-1872. *If you are concerned re: children’s safety or abuse/neglect, please call Child Protection at 763-324-1440, to report those concerns. If you feel children are in imminent danger, please call 911.
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38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

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