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
2. Social Security Number
3. Grade
(Last, first, middle initial)
(SSN)
4. Work address
5. Work e-mail address
(Include street number, city, state and ZIP code)
6. Work telephone number
7. Home address
8. Home e-mail address
(Include street number, city, state and ZIP code)
9. Home telephone number
10.
Category of
11.
Spouse federal
12. Name of spouse
(Last, first, middle initial)
parent
employee
Single
Yes
13. Employing agency of spouse
14. Grade of spouse
Couple
No
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
Reapplication (previously enrolled, not current)
Annual recertification
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
l. Telephone number of child care provider
(Include street number, city, state and ZIP code)
m.
Type of care
Center-based care
(Check one)
Family home-based care
Form authorized for local reproduction
Office of Personnel Management
OPM 1643
Revised May 2003