CHILD CARE SUBSIDY APPLICATION FORM DEPARTMENT (Insert Federal Agency Name) The department may contact the applicant to request clarification on the subsidy application. (Insert name of organization administering the program) You must attach the following documents: 1. Pay statements for the most recent two pay periods for each parent or guardian; 2. A copy of your most recent Federal and State income tax returns; 3. A copy of your child care provider's most recent license or statement of compliance with State and/or local child care regulations; and 4. A completed OPM form 1644, signed by the provider(s) below. Section I - Parent / Legal Guardian Information Applications that are not fully completed or do not contain the information listed below will not be processed and will be returned to the applicant. If you do not provide all of the information requested, you will not receive a subsidy award. When more than one parent works for the Federal Government, subsidies cannot be awarded for the child/children by more than one Federal agency. 1. Name (Last, first, middle initial) 2. Social Security Number (SSN) 4. Work address (Include street number, city, state and ZIP code) 3. Grade 5. Work e-mail address 6. Work telephone number 7. Home address (Include street number, city, state and ZIP code) 8. Home e-mail address 9. Home telephone number 10. Category of 11. Spouse federal parent employee Single Yes Couple 12. Name of spouse (Last, first, middle initial) No 13. Employing agency of spouse 14. Grade of spouse 15. Total family income as reported on adjusted gross income line of most recent IRS form 1040/1040A *Include a copy of the IRS form Section II - Child Information List information for all children for whom you are applying for a subsidy. (If you are applying for more than three children please attach the pertinent information to this form) 1a. Name of first child b. SSN of child c. Date of birth (MM/DD/YYYY) d. Name of child care provider e. Weekly child care cost f. Date of enrollment (MM/DD/YYYY) g. Type of application (Check one) New family Adding/changing family information Annual recertification Reapplication (previously enrolled, not current) Changing provider information (attach new license and OPM Form 1644) h. Is any other form of State, County or Local i. Source of subsidy subsidy being received for the child(ren)? Yes (If "Yes", complete i. and j.) j. Amount of subsidy No k. Address of provider (Include street number, city, state and ZIP code) l. Telephone number of child care provider m. Type of care (Check one) Office of Personnel Management Center-based care Family home-based care Form authorized for local reproduction American LegalNet, Inc. www.FormsWorkFlow.com OPM 1643 Revised May 2003 Section II - Child Information (Continued) 2a. Name of second child b. SSN of child c. Date of birth (MM/DD/YYYY) d. Name of child care provider e. Weekly child care cost f. Date of enrollment (MM/DD/YYYY) g. Type of application (Check one) New family Adding/changing family information Reapplication (previously enrolled, not current) Changing provider information (attach new license and OPM Form 1644) Annual recertification h. Is any other form of State, County or Local i. Source of subsidy subsidy being received for the child(ren)? Yes (If "Yes", complete i. and j.) j. Amount of subsidy No k. Address of provider (Include street number, city, state and ZIP code) l. Telephone number of child care provider m. Type of care Center-based care (Check one) Family home-based care 3a. Name of third child b. SSN of child c. Date of birth (MM/DD/YYYY) d. Name of child care provider e. Weekly child care cost f. Date of enrollment (MM/DD/YYYY) g. Type of application (Check one) New family Adding/changing family information Reapplication (previously enrolled, not current) Changing provider information (attach new license and OPM Form 1644) Annual recertification h. Is any other form of State, County or Local i. Source of subsidy subsidy being received for the child(ren)? Yes (If "Yes", complete i. and j.) j. Amount of subsidy No k. Address of provider (Include street number, city, state and ZIP code) l. Telephone number of child care provider m. Type of care Center-based care (Check one) Family home-based care Section III - Signature of Parent / Legal Guardian 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. In addition, I may be subject to administrative punishment, including the termination of my federal employment. I certify that the above information is true and correct to the best of my knowledge. Signature Date of signature (MM/DD/YYYY) Privacy Act Statement Public Law 107-67, § 630 (September, 2001) 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 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. American LegalNet, Inc. www.FormsWorkFlow.com OPM 1643 (Back) Revised May 2003