Form 2652 - Application For Department Of Defense Child Care Fees

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OMB No. 0704-0515

APPLICATION FOR DEPARTMENT OF DEFENSE CHILD CARE FEES

OMB approval expires

(Read Instructions on back before completing form.)

May 31, 2017

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and

maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive,

Alexandria, VA 22350-3100 (0704-0515). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of

information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO:

OFFICE OF FAMILY POLICY/CHILDREN AND YOUTH, 4800 MARK CENTER DRIVE, SUITE 03G15, ALEXANDRIA, VA 22350-1400

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; 10 U.S.C.

8013, Secretary of the Air Force; DoD Instruction 6060.02, Child Development Programs; Army Regulation 608-10, Child Development Services;

OPNAV Instruction 1700.9 series, Child and Youth Programs; Marine Corps Order P1710.30E, Children, Youth, and Teen Program (CYTP); Air Force

Instruction 34-248, Child Development Programs; and Air Force Instruction 34-249, Youth Programs, and 34-276, Family Child Care.

PRINCIPAL PURPOSE(S): To collect total family income to determine child care fees. When completed, records are covered by one of the

appropriate SORNs: Department of the Army:

Department of the Navy:

Department of the Air Force:

ROUTINE USE(S): Department of the Army records may be disclosed to civilian health and welfare departments/agencies in emergencies.

Department of the Navy records may be disclosed to local, state and Federal officials involved in child care services, if required, in the performance of

their official duties relating to child abuse reporting and investigations. Department of the Air Force records may be disclosed to civilian health and

welfare departments/agencies in emergency situations.

DoD Blanket Routine Uses 1 (Law Enforcement), 4 (Congressional Inquiries), 6 (Required by International Agreement), 9 (Department of Justice for

Litigation), 12 (National Archives and Records Administration), and 15 (Data Breach Remediation) specifically apply to this system. Other DoD Blanket

Routine Uses found at may apply to these records. Any release under a

blanket routine use will be compatible with the purpose of the collection.

DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in application of the highest fee range.

SECTION I - DEPENDENT CHILDREN

2. DATE OF BIRTH

1. NAME OF EACH CHILD

3. AGE

4. CARE REQUESTED (OR ENROLLED)

(LAST, First, Middle Initial)

(YYYYMMDD)

SECTION II - ANNUAL FAMILY INCOME

5. SPONSOR

a. NAME

b. YEARS OF MILITARY/CIVIL SERVICE

(LAST, First, Middle Initial)

c. INCOME

(2) Basic Allowance for Housing

(3) Basic Subsistence

(1) Income Data

(5) Total Income - Sponsor

(4) Other Earned Income

(BAH)

Allowance

(To be completed by

Program Staff)

6. SPOUSE OR OTHER ADULT LIVING IN THE HOME

a. NAME

b. INCOME

(LAST, First, Middle Initial)

8. TOTAL INCOME

7. OTHER EARNED INCOME

(Include income from Blocks 5, 6,

and 7. To be completed by Program Staff.)

SECTION III - CERTIFICATION OF SPONSOR/DESIGNEE

(Required for Category I - IX. Please read the following statement carefully before signing.)

I certify that all of the above information is true and correct and that all family income of the spouse and sponsor is reported. I understand that this

information is being given in order to determine child care fees to be paid and that Federal funds are used to subsidize the cost of child care. I also

understand that the installation commander may verify the information on the application; and that deliberate misrepresentation of this information may

subject me to prosecution under applicable State and Federal laws. See 18 U.S.C. Section 1001.

9. SIGNATURE OF SPONSOR

10. SIGNATURE OF SPOUSE

11. DATE SIGNED

(YYYYMMDD)

SECTION IV - FOR CHILD DEVELOPMENT PROGRAM USE ONLY

14. DATE OF APPROVAL

15. NAME OF CHILD DEVELOPMENT

12. CATEGORY OF APPROVAL

13. AUTHORIZED FEES

PROGRAM OFFICIAL

(YYYYMMDD)