Get Ccdf Indiana 2014-2024

CHILD CARE and DEVELOPMENT FUND CCDF Pre-application v10-14 Date Completed Phone Area Code Number Last Name First Name Street Address City County Zip Are you check one Working or Attending School If you are working are you paid Weekly Bi-Weekly Other Is a spouse/parent of the child ren living with you Yes No If yes are they Working Attending School or Other PLEASE NOTE YOU MUST ATTACH A COPY OF A RECENT PAY-STUB FOR YOURSELF AND OTHER ADULT IF APPLICABLE. IF SELF EMPLOYED ATTACH TAX FORM SCHEDULE C not more than 6 months old or STATEMENT OF PROFIT AND LOSS. Complete the table below for ALL household members including yourself. LIST ALL MEMBERS OF THE HOUSEHOLD Last Name First Name Date of Birth Social Security Number Optional xxx-xxxxx-xxxxx-xxxxx-xxxxx-xx- Does child need child care services Does child have special needs See Note N/A Yes No Relationship to Applicant SELF Licensed Foster Parent Special Needs Note Child must be enrolled in Children with Special Health Care Services First Steps Public School Special Education IEP or Head Start professionally diagnosed with disabilities receiving Supplemental Social Security or have a statement from health professional. Documentation must be submitted. I hereby certify all the information provided is true and correct to the best of my knowledge. I understand submission of this application does not guarantee services will be provided* Further I understand I will be asked to verify information supplied on this pre-application when and if I complete an application for services. TANF month Documentation of TANF is required Signed Date Other Sources of Income Child Support Unemployment month Other Your pre-application must be renewed every 90 days. This process is initiated by the Intake Agency by mail* Please notify the agency of any changes to your application including address. Check all categories which best describe who is currently watching your child ren. Licensed Child Care Center Unlicensed Registered Child Care Ministry Friend / Relative / Neighbor Head Start Pre-School Before/After School Program Boys/Girls Club Nanny In my own home No one at this time Other RETURN TO CHILDREN S BUREAU FAMILY PLACE 3801 N* TEMPLE AVENUE INDIANAPOLIS IN 46205 OR FAX TO 317-545-1069. I understand submission of this application does not guarantee services will be provided* Further I understand I will be asked to verify information supplied on this pre-application when and if I complete an application for services. TANF month Documentation of TANF is required Signed Date Other Sources of Income Child Support Unemployment month Other Your pre-application must be renewed every 90 days. TANF month Documentation of TANF is required Signed Date Other Sources of Income Child Support Unemployment month Other Your pre-application must be renewed every 90 days. This process is initiated by the Intake Agency by mail* Please notify the agency of any changes to your application including address. This process is initiated by the Intake Agency by mail* Please notify the agency of any changes to your application including address. Check all categories which best describe who is currently watching your child ren. Licensed Child Care Center Unlicensed Registered Child Care Ministry Friend / Relative / Neighbor Head Start Pre-School Before/After School Program Boys/Girls Club Nanny In my own home No one at this time Other RETURN TO CHILDREN S BUREAU FAMILY PLACE 3801 N* TEMPLE AVENUE INDIANAPOLIS IN 46205 OR FAX TO 317-545-1069. .