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:_________________________________________________________________________