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CHILD CARE AND DEVELOPMENT FUND CCDF VOUCHER PROGRAM WAGE DETAIL FORM v5-01--13 NOTE Check stubs or employer s cancelled checks front and back must be included with this form for the pay date listed. APPLICANT / CO-APPLICANT SECTION To be completed by the employee. I hereby authorize and request you to provide the Child Care and Development Fund information as specified below. This information is necessary to establish my eligibility for childcare assistance. This is without any liability to you whatsoever. You may retain a copy of this authorization for your records. Employee Signature Last 4 of Social Security Number Printed Name DatePhone EMPLOYER SECTION To be completed by your Employer ONLY Please complete the following information for the period of to Check Number Actual Date Paid Gross Wages Paid Total Hours Worked If cancelled check are provided Is this individual still employed Yes No If NO please provide last day worked Employer s Name Business Phone Number Street Address City Zip Please provide your business s EIN number and/or attach your business card. Signature Printed Name and Title Date completed Note This form cannot be accepted without the EIN number and/or business card. If you have questions regarding this form please contact Chances And Services for Youth 1101 S* 13th Street Terre Haute IN 47802 Phone 812 232-3952 Fax 812 232-1731 www. I hereby authorize and request you to provide the Child Care and Development Fund information as specified below. This information is necessary to establish my eligibility for childcare assistance. This is without any liability to you whatsoever. This information is necessary to establish my eligibility for childcare assistance. This is without any liability to you whatsoever. You may retain a copy of this authorization for your records. Employee Signature Last 4 of Social Security Number Printed Name DatePhone EMPLOYER SECTION To be completed by your Employer ONLY Please complete the following information for the period of to Check Number Actual Date Paid Gross Wages Paid Total Hours Worked If cancelled check are provided Is this individual still employed Yes No If NO please provide last day worked Employer s Name Business Phone Number Street Address City Zip Please provide your business s EIN number and/or attach your business card. You may retain a copy of this authorization for your records. Employee Signature Last 4 of Social Security Number Printed Name DatePhone EMPLOYER SECTION To be completed by your Employer ONLY Please complete the following information for the period of to Check Number Actual Date Paid Gross Wages Paid Total Hours Worked If cancelled check are provided Is this individual still employed Yes No If NO please provide last day worked Employer s Name Business Phone Number Street Address City Zip Please provide your business s EIN number and/or attach your business card. Signature Printed Name and Title Date completed Note This form cannot be accepted without the EIN number and/or business card.

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