Parent/applicant Worksheet (Child Care And Development Fund Voucher Program) (Page 2 of 3) in pdf

(CCDF Parent Worksheet) PAGE 2 of 3

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

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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.

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I understand that if I fail to use my child care assistance within sixty (60) days, it will be voided.

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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.

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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 of my behalf.

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I understand it is my responsibility to report to the Intake if my Hoosier Works for Child Care card is lost or stolen.

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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:

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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.

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I understand 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.

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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.

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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 a new address or I obtain a new phone

number within ten (10) calendar days of the change and provide supporting documentation, if necessary.

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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:

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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 on Friday.

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I understand the choice of caregiver is not only my choice, it is my responsibility.

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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.

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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.

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I understand parents, step-parents or legal guardians will not be paid as caregivers for their own children.

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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:

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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.

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I understand my right to file a written complaint.

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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:

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Allowing another person to use my Hoosier Works for Child Care card to document attendance;

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Failing to electronically document my child/children’s attendance; and/or

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Failing to pay my co-pay.