Refer to CCDF Eligibility Documentation Letter listing acceptable documents to send. All forms must be signed and dated the same date. All documentation submitted must be within the prior 60 days of your packet signature date unless stated otherwise. This includes the Provider Information Page.


  • Parent/Applicant Worksheet: Must be fully completed, signed and dated. You must place applicable income in all boxes. If you do not receive, place a zero in the box. Questions on reverse side must be fully answered. For questions that don’t apply to you please write “NA”. Please do not forget to sign the Parent/Applicant Worksheet. Signature Line is on Page 3.
  • Residency: Must include your full name, full address and be dated within the current 60 day period of your Parent/Applicant Worksheet.
  • Service Need for Adults: Submit at least one pay stub which must be within 60 days from applicant signature date on State Form 805 or Parent/Applicant Worksheet. If attending school must submit current school schedule. IF YOU HAVE CHANGED EMPLOYMENT WITHIN THE LAST 30 DAYS, YOU MUST PROVIDE ANY CHECK STUBS FROM PREVIOUS EMPLOYER WITHIN THE LAST 30 DAYS OR LAST CHECK.
  • Other Countable Income: If you receive Unemployment go to the following website: https://uplink.in.gov/CSS/CSSClaimHomePage.htm . Unemployment documentation must be dated the samedate you date your packet and print all unemployment amounts received. If you receive Social Security Benefits/SSI, you must provide a CURRENT YEAR benefit letter. If you receive TANF, you must provide a TANF benefit letter received within the last 12 months
  • Provider Information Page: This form must be fully completed by your provider. Provider must include all rates in each column per child.


Forms are available on our website at www.FireflyIN.org
  • Wage Detail Form: To be completed if you are paid by business/personal check and requires copies of cancelled checks, front and back, for each pay date listed.
  • • Verification of New Employment: Must be completed if you have a new job and no pay stubs to submit.
  • • Tipped Employee Worksheet: If you receive tips on your pay stubs you are required to complete this form.
  • • Name Attestation: If any document submitted for adults on application have a different or misspelled first and last name this form must be completed.
  • • Statement of Profit/Loss: If you or the other adult are self employed this form must be fully completed. Requires an IRS Tax Transcript that includes a Schedule C for the previous tax year. Partnerships require Form 1065 & Schedule K for previous tax year.
  • • Provider – Parent Statement: Must be completed if you are employed with a Daycare Provider. Your provider and you must complete the form.
  • • Secondary School Enrollment Verification: To be completed if you are in middle school or high school. This form is not for students in college.
  • • Hoosier Works for Child Care Card Authorization: To be completed if your current swipe card is not working or you have lost your card.


1) Review all forms to assure you have signed and dated them. Some forms are front and back. Review carefully.
2) Make sure documents you send are legible. If documents are not legible they will not be accepted and your reauthorization will not be processed.
3) If you have any questions, please call 317-545-5281 or 1-866-287-2420 Ext 16002
4) Return your authorization packet and documents by the due date.
5) If mailing your packet, it must be weighed by the Post Office to assure correct postage. We do not accept postage due packets.
6) If faxing your packet all documents and forms must be legible or they will not be accepted. Remember, fax machines do not send both sides of two sided documents.

Firefly Children and Family Alliance 3801 N. Temple Ave. Indianapolis, IN 46205

FAX NUMBER: 317-545-1069
(please call to confirm receipt)

Please contact or email office to confirm receipt

EMAIL ADDRESS: ccdfvouchers@FireflyIN.org


In order to be considered for the Child Care Voucher Program you must be currently working and/or attending school or participating in an eligible IMPACT activity or have a referral from your DCS worker. To determine eligibility the following items are needed from you and your spouse and/or child’s father, if applicable. If you have questions, please call: 317-545-5281 ext 16002. You may also call our toll-free number at 1-866-287-2420 ext 16002. Without all of the proper documentation we will not be able to complete your appointment and process your application.

Proof of Identity (must be valid)

  • Parent(s) Driver’s License or State ID or Passport or Military ID or School ID or Work ID
  • For all children in household MUST have date of birth listed: Birth Certificates; Hospital Issued certificate of birth; Birth confirmation letter; ICES Screen; Court record of adoption, paternity, or foster placement; passport; permanent residency card; Medicaid card; Immunization Records w/Social Security Card or School Records or State ID
  • *Foster Parents: All of the above plus: Valid Foster Parent License which matches the foster parent’s residency verification and Current Placement letter from the DCS/Foster agency caseworker signed or current per diem documentation with child(ren)’s name on it or Court placement order or State Form 3319.

Proof of a service need (working and/or attending school and/or participating in TANF/IMPACT Program)

  • If working: Submit at least one pay stub which must be within 60 days from applicant signature date on State Form 805 or Parent/Applicant Worksheet. Check stubs must include your name AND Gross wages OR at least one cancelled check (front and back), which must be within 60 days from applicant signature date on State Form 805 or Parent/Applicant Worksheet. Cancelled checks must include – employers name imprinted in the upper left corner of check, Applicants/Co-Applicants name on pay to the order of line; current date on date line; amount paid; check has been fully negotiated (cashed) as evidenced on the back of the cancelled check by the financial institution; AND Wage Detail Form completed by employer. A computer generated wage history summary from your employer or State Form 54092 may also be accepted.
  • If starting new job: A signed completed New Hire Verification Form
  • If attending an education program through a certified or accredited education/training organization or institution: Current School documentation must include Student Name, School Name, Credit hours taken and/or hours of participation, and Semester dates or begin and end date, if applicable. Please Note: Those with two associates, one four (4) year degree, or masters program do not qualify for CCDF services under education.
  • If TANF/IMPACT: referral form (for new TANF/IMPACT clients: this was sent by your worker to Children’s Bureau)
  • If DCS (Department of Child Services): a written statement from CPS caseworker indicating the child(ren) are living in their own home, the child(ren) need care outside their own home, amount of care needed per week, CPS caseworker’s contact information (This is for biological parents only)

Verification of Residency

(must be valid/received in the previous 60 days of your signature date)
  • Proof of residency document must include: name of applicant or co-applicant, complete address to include street address. City and/or zip code and dated no more than 60 days prior to applicant signature date on State Form 805 or Parent/Applicant Worksheet. A lease for the current lease period may be accepted

Verification of All other sources of income

(if applicable)
  • Social Security (SSI) benefit letter
  • Current Unemployment print out showing income within 30 days from applicant signature date
  • Current TANF benefit letter (any TANF/IMPACT clients must have referral and all ICES screens)

Information from CCDF qualified childcare provider:

  • Provider Information Page completed by a licensed or certified CCDF provider only. To determine if your child care provider is CCDF eligible contact Child Care Resource and Referral Line (CCRR) at 1-800-299-1627 (If you work for the child care provider where your children attend you must provide the agency parent provider form)