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

(CCDF Parent Worksheet) PAGE 3 of 3

18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies,

conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious, or fraudulent statements or representations, or makes any false writing or document knowing the

same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations

are subject to fines of up to $500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically

authorized by the sentencing statute.

Section 35-43-5-7: Welfare fraud(a) A person who knowingly or intentionally: (1) obtains public relief or assistance by means of impersonation, fictitious transfer, false or misleading oral or written

statement, fraudulent conveyance, or other fraudulent means; (2) acquires, possesses, uses, transfers, sells, trades, issues, or disposes of: (A) an authorization document to obtain public relief or

assistance; or (B) public relief or assistance; except as authorized by law; (3) uses, transfers, acquires, issues, or possesses a blank or incomplete authorization document to participate in public relief

or assistance programs, except as authorized by law; (4) counterfeits or alters an authorization document to receive public relief or assistance, or knowingly uses, transfers, acquires, or possesses a

counterfeit or altered authorization document to receive public relief or assistance; or (5) conceals information for the purpose of receiving public relief or assistance to which he is not entitled;

commits welfare fraud, a Class A misdemeanor, except as provided in subsection (b). (b) The offense is: (1) a Class D felony if: (A) the amount of public relief or assistance involved is more than two

hundred fifty dollars ($250) but less than two thousand five hundred dollars ($2,500); or (B) the amount involved is not more than two hundred fifty dollars ($250) and the person has a prior

conviction of welfare fraud under this section; and (2) a Class C felony if the amount of public relief or assistance involved is two thousand five hundred dollars ($2,500) or more, regardless of

whether the person has a prior conviction of welfare fraud under this section. (c) Whenever a person is convicted of welfare fraud under this section, the clerk of the sentencing court shall certify to

the appropriate state agency and the appropriate agency of the county of the defendant's residence: (1) his conviction; and (2) whether the defendant is placed on probation and restitution is ordered

under IC 35-38-2.

I have read and understand the Penalties for Falsifying Information, as printed in this application. I understand that any deliberate omission, misrepresentation, or falsification of any information

contained in this application or contained in any communication supplying information to Family and Social Services Administration/Office of Early Childhood and Out of School Learning, or any

deliberate alteration of any text on this application form, may be punished by criminal, civil, or administrative penalties including, but not limited to, the denial or revocation of CCDF benefits, and/or

the imposition of fines, civil damages, and/or imprisonment.

Parent / Applicant Signature _______________________________________________________ Printed Name ____________________________________________ Date ____________________

ATTENTION! The income and residency documentation you submit must be dated no earlier than 30 days before the

date you sign this worksheet. All documentation must be dated within the 30 days prior to the signature date.

NOTES TO YOUR CCDF INTAKE AGENT: