Northwest Indiana Child Care Development Fund Program

Geminus Corporation/NW Indiana CCDF Program 8400 Louisiana Street, Merrillville, IN 46410 (888)757-1957 or (219)757-1957  Fax (219)738-5283 CHILD CARE and DEVELOPMENT FUND (CCDF) VOUCHER PROGRAM REPORT OF CHANGE FORM You are required to report changes within 10 calendar days from the date of occurrence. A Non-Compliance Form will be issued if you fail to report changes timely and may result in repayment of childcare benefits. You must report an address change, change in family size, change in TANF status, and loss of service need. In order to be considered for a leave from your activity, the leave cannot exceed 13 weeks if you continue using services/16 weeks if you do not use the services. In order to have your case transferred to another county in Indiana the transfer must be completed within 30 days of the move. If you report the move late, your case will not be transferred. You will need to place your name on the waiting list in the new county.

I, Case Name ______SS# XXX-XX-______Date ______(P L E A S E P R I N T)  Transfer my case to ______County, Indiana. My phone #(______)______

Date of move ______. My new address ______. (new street address, apt #, city, state, zip code)  My school or job ended on ______& I am requesting childcare so I can job search.

 I am no longer participating in Impact.

 I started a new job or school on ______. (Attach a copy of your class schedule, new hire letter or current check stub.)

 Please close my case. I no longer need childcare assistance as of ______.

 I adopted my foster child ______(child’s name) on ______(date).

 My child ______will have visitation with ______(name of person) and will not need the childcare services effective ______will need care to resume on ______.

 I am on leave from my activity. (Attach a statement from employer stating when leave started and expected return to work date or submit a copy of your FMLA paperwork.)

 I have moved. Date moved ______. ______New Street Address Apt # City State Zip Phone Number Attach proof of new address. The item must be dated within 30 days from the date you sign this form. Submit one item: ■rent receipt ■mortgage statement based on statement date or print date ■utility bill (any type of phone bill will not be accepted) ■check stub ■valid INS green card ■valid driver’s license or State ID that has not expired ■lease that has not expired which states your name, full address including city/state/zip code and period of the lease ■college class schedule for the current semester if your address prints on the schedule ■documentation from a homeless shelter or domestic violence shelter which states the county of residence. The shelter’s PO box can be used as your address for mailing purposes. ■letter from the DFR (Welfare Department) or Arbor (Impact Office) ■online documentation from the United States Postal Service showing an updated or changed address which included a confirmation code ■non-window envelope from mail you received at address with postmark. ■unemployment insurance printout ■high school students can call our office and request a form that the school can complete ■correspondence from federal agencies such as the Social Security Administration ■ valid Indiana Vehicle Registration ■ documentation of homelessness provided by the DFR  My household size has changed. Check one: Someone has moved in  or has left  the home. Name Of Person ______Relationship to me______Date Of Birth______Date change occurred ______Is childcare needed for this individual? ____yes ____no Other Changes:______