Fillable Va Form 0730a - Child Care Subsidy Application Form printable pdf download

OMB Number: 2900-0717

Respondent Burden: 20 minutes

CHILD CARE SUBSIDY APPLICATION FORM

PRIVACY ACT STATEMENT - Public Law 107-67, § 630 (September 2001) confers regulatory authority on the Department of Veterans Affairs 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 statements 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.

SECTION I - PARENT/LEGAL GUARDIAN INFORMATION

NOTE: 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 through the

submitting HR office. 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

3. JOB SERIES/GRADE

4. ORGANIZATIONAL CODE (See list

of codes at bottom of Section I)

5. WORK ADDRESS (Include street number, city, state and ZIP Code)

6. WORK E-MAIL ADDRESS

7. WORK TELEPHONE NUMBER/EXTENSION

8. HOME ADDRESS (Include street number, city, state and ZIP Code)

9. HOME E-MAIL ADDRESS

10. HOME TELEPHONE NUMBER

11. CATEGORY OF

12. IS SPOUSE A

13. NAME OF SPOUSE (Last, first, middle initial)

14. GRADE OF SPOUSE

PARENT

FEDERAL EMPLOYEE?

SINGLE

YES

15. EMPLOYING AGENCY OF SPOUSE

COUPLE

16. TOTAL FAMILY INCOME AS REPORTED ON ADJUSTED GROSS INCOME LINE OF MOST RECENT IRS FORM 1040 OR 1040A.

(007)

Assistant Secretary for Operations, Security and Preparedness

ORGANIZATIONAL CODES

(008)

Assistant Secretary for Policy and Planning

(00)

Office of the Secretary

(009)

Assistant Secretary for Congressional & Legislative Affairs

(00CFM) Assistant Secretary for Construction & Facilities Management

(01)

Board of Veterans' Appeals

(002)

Assistant Secretary for Public & Intergovernmental Affairs

(02)

General Counsel

(003)

Office of Acquisition, Logistics & Construction

(10M)

Veterans Health Administration - Medical Services

(004A)

Assistant Secretary for Management (Finance Fund)

(10F)

Veterans Health Administration - Medical Facilities

(004G)

Assistant Secretary for Management (GOE)

(10R)

Veterans Health Administration - Research

(004F)

Assistant Secretary for Management (Franchise Fund)

(10E)

Veterans Health Administration - Medical Administration

(005G)

Assistant Secretary for Information & Technology (GOE)

(10C)

Veterans Health Administration - Canteen Service

(005F)

Assistant Secretary for Information & Technology (Franchise Fund)

(20)

Veterans Benefits Administration

(006E)

Corporate Senior Executive Management Office

(40)

National Cemetery Administration

(006G)

Assistant Secretary for Human Resources & Administration (GOE)

(50)

Inspector General

SECTION II - CHILD INFORMATION

INSTRUCTION: 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.)

1B. DATE OF BIRTH (MM/DD/YYYY)

1A. NAME OF FIRST CHILD

1C. NAME OF CHILD CARE PROVIDER

1D. WEEKLY CHILD CARE COST

1E. DATE OF ENROLLMENT (MM/DD/YYYY)

1F. TYPE OF APPLICATION? (Check only one)

1G. ENTER LAST DAY WITH PREVIOUS

PROVIDER (MM/DD/YYYY)

NEW FAMILY

REAPPLICATION (Previously enrolled, not current.)

ANNUAL RECERTIFICATION