Child Care Subsidy Application Form Department - Opm Page 2
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1
2Section 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)
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
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)
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
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.
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OPM 1643 (Back)
Revised May 2003
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