Child Care And Development Fund Pre-Application Template

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RETURN TO CHILDREN’S BUREAU FAMILY PLACE, 3801 N. TEMPLE AVENUE, INDIANAPOLIS, IN 46205 OR FAX 317-545-1069
CHILD CARE and DEVELOPMENT FUND (CCDF) Pre-application
(v2-16)
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 ______________________
If spouse/parent is working, are they paid
Weekly
Bi-Weekly
Other ____________________
PLEASE NOTE: YOU MUST ATTACH A COPY OF A RECENT PAY-STUB FOR YOURSELF AND OTHER ADULT, IF APPLICABLE. IF SELF
EMPLOYED ATTACH STATEMENT OF PROFIT AND LOSS FOR PREVIOUS MONTH.
Complete the table below for ALL household members including yourself.
Does child need
Does child have
Relationship
Licensed
OTHER SOURCES OF
LIST ALL MEMBERS OF THE HOUSEHOLD
Date of Birth
child care
special needs?
to Applicant
Foster Parent
INCOME
Last Name, First Name
services?
(See Note)
Child Support $__________
N/A
N/A
SELF
Yes
No
mo.
Yes
No
Yes
No
Yes
No
Social Security $_________
mo.
N/A
Yes
No
Yes
No
TANF* $ _______________
N/A
Yes
No
Yes
No
mo.
N/A
(*Documentation required)
Yes
No
Yes
No
Unemployment $ ________ mo.
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.)
Other $ ________________ mo.
Additional Questions
Check all categories which best describe who
AFFIRMATION STATEMENT
I hereby certify all the information provided is true and correct to
is currently watching your child(ren).
1. Are you and your family currently living in a
the best of my knowledge. I understand submission of this
___ Licensed Child Care Center
homeless or domestic violence shelter?
application does not guarantee services will be provided. Further, I
___ Licensed Child Care Home
understand I will be asked to verify information supplied on this
Yes or No
___ Unlicensed Registered Child Care Ministry
pre-application when and if I complete an application for services.
2. Are you and your family currently living in a
___ Friend / Relative / Neighbor
___ Head Start
car, park or other public place?
___ Pre-School
Signed, ____________________________ Date _________
Yes or No
___ Before/After School Program
3. Do your family assets (cash, retirement, real
___ Boys/Girls Club
Your pre-application must be renewed every 90 days. This
property, and investments) total more than
___ Nanny (In my own home)
process is initiated by the Intake Agency by mail.
Please
one million?
notify the agency of any changes to your application,
___ No one at this time
including address.
___ Other ___________________________
Yes or No

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