Form Approved: OMB No. 3206-0240 CHILD CARE PROVIDER INFORMATION FOR THE CHILD CARE SUBSIDY PROGRAM FOR FEDERAL EMPLOYEES This information is required by law to verify that you are a licensed and/or regulated provider. Child Care Provider: Complete this form and return it to the parent along with a copy of your latest license and/or regulatory document. Employee: Return the completed form and copy of the license and/or regulatory document to the agency Child Care Subsidy Coordinator. Section I - Parent Information 1. Name of parent/legal guardian 2. Federal agency of parent Section II - Provider Information 1. Type of provider (Check one) Family Child Care Child Care Center Federally Sponsored Child Care Center 2. Name of child care provider 3. Child Care Provider's address (including street number, city, state and ZIP code) 4. Provider telephone number 5. Provider fax number 6. Tax identification number or Social Security Number 7. Provider e-mail address 8. License number of provider 9. State in which license is issued 10. License expiration date (MM/DD/YYYY) Section III - Child Information Please complete the information below for each child: a. Name of child (Last, first, middle initial) b. Birth date of child (MM/DD/YYYY) c. Does the child receive any other subsidy?(If "Yes", complete d. and e.) d. Source of subsidy e. Amount of subsidy f. Total weekly fee for child Yes $ $ Yes No $ $ Yes No $ $ Yes No $ $ Yes Office of Personnel Management No No $ $ Form authorized for local reproduction Page 1 of 2 OPM 1644 Revised April 2009 Previous editions not usable American LegalNet, Inc. www.FormsWorkFlow.com Section IV - Information on Provider's Financial Institution's Account for Payment to Provider 2. Financial institution's routing number 1. Name of financial institution 3. Address of financial institution (Include street number, city, state, and ZIP code) 4. Type of account (For payment deposit) (Check one) Checking 5. Provider account number Savings Section V - Signature of Provider I understand that it is a Federal crime under United States Code 18, Section 1001, to make a false statement on this form. If I make a false statement, I agree to be subject to criminal prosecution and punishment including a fine, imprisonment, or both. 1. Name of provider 2. Type of provider representative 3. Signature of provider (I certify that the above information is true and correct to the best of my knowledge.) 4. Date of signature (MM/DD/YYYY) Privacy Act Statement: Public Law 106-554, § 633 (September 29, 2000) confers regulatory authority on OPM for agency use of appropriated funds for child care costs for lower income Federal employees. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal Government furnish a Social Security Number or tax identification number. This is an amendment to title 31, Section 7701. The primary use of these Social Security Numbers and tax identification numbers will be for identification purposes in determining eligibility for child care subsidy. The primary use of information regarding family income (copies of pay slips and tax returns), name of current child care provider, copies of the provider's license, statement of compliance, and information about other child care subsidies is also used to determine eligibility for child care subsidy. Disclosure of the above information is voluntary, but failure to provide all of the requested information may result in denial of your application. Public Burden Statement: We think this form takes an average of 10 minutes to complete including the time for getting the needed data and reviewing both the instructions and completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Reports and Forms Manager, Paperwork Reduction (3206-0240), Washington, DC 20415-7900. The OMB Number, 3206-0240, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Page 2 of 2 OPM 1644 (Back) Revised April 2009 Previous editions not usable American LegalNet, Inc. www.FormsWorkFlow.com