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.

• 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.

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)

• 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

• 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)

• 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)

I understand the following pertaining to my Hoosier Works for Child Care (HWCC) card and recording my child’s attendance:

• I understand I will be required to electronically document my child(ren)’s attendance information. I will only utilize my Hoosier Work for Child Care card to document attendance when it truly reflects the care provided.
• I understand that if I fail to use my child care assistance within sixty (60) days, it will be voided.
• I understand I may only electronically, or otherwise, document my child’s attendance when my child is attending the location where my voucher has been assigned.
• I understand I may not leave my Hoosier Works for Child Care card with my child care provider. I agree to keep my personal identification number (PIN) confidential as it is my electronic signature. I understand failure to comply with this may result in termination of my child care benefits and repayment of child care assistance paid on my behalf.
• I understand it is my responsibility to report to the Intake if my Hoosier Works for Child Care card is lost or stolen.
• I understand I can utilize up to twenty (20) Personal Days. Personal Day claims are to be used at my discretion for days when the provider was open for business and my child/children were scheduled to attend but did not attend any part of the day.

I understand the following pertaining to my obligations of verifying my eligibility for CCDF benefits:

• I understand it is my responsibility to furnish the Intake Agent with complete and accurate information including, but not limited to, income and family composition. I understand I will be required to submit proof of information provided.
• I understand that I may be requested to verify these statements and give my consent to the agency, from where I am requesting services, to make any necessary contacts and verify statements.
• I understand subsidized child care will not begin until all forms are completed and I have received written notice from the Office or their representative.
• I understand I must report to the Intake Agent when my service need ends, my TANF status changes, my family composition changes, I move to another State I obtain a new phone number, I have total assets which exceed 1 million dollars or a change in income which exceeds 85% of the State median income (SMI), within ten (10) calendar days of the change and provide supporting documentation, if necessary.
• I understand I may be asked to cooperate with state and/or federal personnel in any investigation. I further understand my failure to cooperate may result in termination from the program.

I understand the following pertaining to my child care provider:

• I understand I must request a provider change by submitting a complete and current Provider Information Page to the CCDF Intake Office no later than noon the day before the last business day of the week.
• I understand the choice of caregiver is not only my choice, it is my responsibility
• I understand it is my responsibility to report any suspected child abuse and neglect to the proper authority and others have the same responsibility concerning my child/children
• I understand reimbursement for my child’s care will be made directly to the provider, unless the care is provided in my home by a non-resident, in which case the payment will be made directly to me. It is my responsibility to reimburse the provider for services rendered as well as any co-payments. I also understand it is my responsibility to withhold and make all applicable Internal Revenue Service (IRS) payments for my child care provider and for the end of the year reporting to the IRS
• I understand parents, step-parents or legal guardians will not be paid as caregivers for their own children.
• I understand that failure to pay any child care co-payment could result in my family being terminated from this funding assistance.

I understand my rights in receiving child care benefits through the CCDF program:

• I understand information concerning my family regarding the CCDF voucher program, and the services I receive, will be treated as confidential and will be used solely for the administration of the CCDF voucher program.
• I understand my right to file a written complaint.
• I understand I can submit a written appeal if I disagree with an action taken regarding my eligibility for CCDF.

I understand my child care may be terminated for any of the following reasons:

• Failure to respond to requests for additional information related to eligibility determination from The Office or its agents within the required time frame
• Failure to pay weekly copayment owed, if reported within thirty (30) days from first missed payment.
• Failure to document a CCDF eligible child’s attendance in the manner required by the Office.
• Failure to fully reimburse CCDF eligible in-home (nanny) provider
• Submitting attendance claims for time the CCDF eligible child was not in attendance, with the exception of approved holidays and personal days, as allowed by the Office.
• Allowing an unauthorized person, including the CCDF eligible child care provider, to possess a CCDF card, card number, or Personal Identification Number, password or any other tool for entering electronic attendance information, as applicable.
• Failure to remain current on any existing repayment agreements determined by the Office
• Failure to select a CCDF eligible provider

I understand my child care will be terminated for any of the following reasons:

• Excessive unexplained absences.
• A change of residency outside of the State
• Substantiated fraud or intentional program violations
• Failure to provide complete information at time of authorization or update
• CCDF Household income does not meet financial eligibility
• CCDF Household does not meet service need requirements
• Copayment exceeds total weekly subsidy
• Failure to select a CCDF eligible provider

Do you Receive:
Amount Per Month

By signing this form, I am acknowledging I have received this HOOSIER WORKS FOR CHILD CARE CARD and understand the policies related to its use.

• I understand I may not allow anyone, including my child care provider, to possess or use my Hoosier Works for Child Care card to authorize electronic attendance transactions for child(ren).
• I understand a provider should never attempt to force me to violate this policy. If a provider does attempt to force me to violate this policy, I shall immediately report it to the Local Intake Agent for referral to the state.
• Exceptions to this policy will only be accepted with written documentation from the Office.

Failure to follow the above policy could lead to negative action taken against me and/or my child care provider, up to and including termination from the Child Care and Development Fund (CCDF) voucher program.