Fillable Va Form 0730h - Va Child Care Subsidy Program Benefit Payment Request Form printable pdf download

VA CHILD CARE SUBSIDY PROGRAM

BENEFIT PAYMENT REQUEST FORM

PRIVACY ACT STATEMENT - Public Law 107-67, Section 630 (November 12, 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 furnishes 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 (SSN) and tax identification numbers will be for identification purposes in assuring

licensure and/or regulation compliance. This compliance is necessary for the purpose of determining Federal employee eligibility for child care subsidy.

Disclosure of the above information is voluntary, but failure to provide all of the requested information may result in the denial of your request for

payment of child care subsidy benefits.

INSTRUCTIONS: Employees approved to participate in the VA Child Care Subsidy Program must use this form to request monthly child care subsidy

benefit payments. A separate form must be prepared for each month benefits are requested and should not be submitted until child care services for the

month have been provided. A copy of the child care provider's invoice for the month must be attached to each form and mailed to (faxes and e-mail

VA Child Care Subsidy Program Office (05CCSP)

submissions are not acceptable): Department of Veterans Affairs,

, 810 Vermont Avenue,

NW, Washington, DC 20420. The child care provider's invoice should include the name of the provider or company, invoice number, the provider's

Federal tax identification number, a description of services and total cost of monthly services.

Completed forms must be received at VA not later than the last day of the month following the month for which payment is requested. For example, if a

subsidy benefit is requested for October 2009, the completed form for October 2009 must be received by VA no later than November 30, 2009.

Please print clearly.

NOTE: You are responsible for the payment of your total child care cost and must pay the full amount on all invoices issued to you by your child care

provider. As a participant in the VA Child Care Subsidy Program, you are eligible to receive a subsidy to be applied towards your child care costs. Your

monthly child care subsidy will be forwarded to your child care provider on your behalf. Any arrangement you make with your provider regarding the

manner in which your child care subsidy benefits are credited to your account is between you and your child care provider.

SECTION I - PARENT/LEGAL GUARDIAN INFORMATION

1. NAME AND HOME ADDRESS OF EMPLOYEE

2. HOME PHONE NUMBER

4. WORK ADDRESS (Include Street Number,

5. WORK PHONE NUMBER

(Include Street Number, City, State and ZIP Code)

City, State and ZIP Code)

6. STATION NUMBER

3. HOME E-MAIL ADDRESS (If applicable)

7. WORK E-MAIL ADDRESS (If applicable)

SECTION II - CHILD CARE PROVIDER INFORMATION

1. NAME AND ADDRESS OF CHILD CARE PROVIDER/COMPANY (Include Street Number,

2. TELEPHONE NUMBER OF CHILD CARE PROVIDER

City, State and Zip Code)

3. E-MAIL ADDRESS OF CHILD CARE PROVIDER

4a. CHILD'S NAME:

AGE:

4c. CHILD'S NAME:

AGE:

4b. CHILD'S NAME:

AGE:

4d. CHILD'S NAME:

AGE:

5. INDICATE THE MONTH AND YEAR FOR WHICH YOU ARE REQUESTING A SUBSIDY FOR CHILD CARE PROVIDER COSTS (MONTH/YEAR)

6. INDICATE BELOW THE FULL CHILD CARE COST FOR EACH WEEK OF THE MONTH YOU ARE REQUESTING A CHILD CARE SUBSIDY BENEFIT

WEEK 1 ENDING DATE:

WEEK 2 ENDING DATE:

WEEK 3 ENDING DATE:

WEEK 4 ENDING DATE:

WEEK 5 ENDING DATE:

MONTHLY TOTAL:

WEEK 1 TOTAL CHARGES:

WEEK 2 TOTAL CHARGES:

WEEK 3 TOTAL CHARGES:

WEEK 4 TOTAL CHARGES:

WEEK 5 TOTAL CHARGES:

SECTION III - CERTIFICATION AND SIGNATURE OF EMPLOYEE

CERTIFICATION: I certify that the above information is true and correct and that the above child care services were received for the period of time

this request covers. I understand that failure to truthfully set forth this information could result in the loss of child care subsidy from the Department of

Veterans Affairs.

Employee's Signature

Date of Signature (MM/DD/YYYY)

SECTION IV - FOR APPROVING OFFICE USE ONLY

MONTHLY COST:

VA PERCENTAGE:

SUBSIDY AMOUNT:

EXPLANATION:

DISAPPROVED

AUTHORIZING OFFICIAL SIGNATURE:

DATE:

COMMENT: