Child Care Verification Form - Ut Southwestern printable pdf download

CHILD CARE VERIFICATION FORM

□

Is your child in daycare?

Yes

If yes, give name of daycare center and contact #: _____________________________________

□

Do you pay an individual other than a daycare facility to care for your child?

Yes

If you answered yes to one of these questions, please complete the information below and

return this form, receipts (at least 4 weeks), and a letter from the daycare or caregiver (letter

must be notarized if caregiver). The letter should specify your monthly charges.

You indicated on the Free Application for Federal Student Aid (FAFSA) that you had

dependents.

If those dependents are children that will require you to pay child daycare

expenses, please list below the names, ages, and amounts paid for each child.

Name

Age

Monthly Expense

May - August

August - May

Are you married?

Yes

□

If yes, is your spouse employed outside the home? Yes

____Full-time

____Part-time____Hours per week

Is your spouse a college student? Yes

If yes, name of college: _______________

____Full-time

____Part-time____Hours per semester

If the child(dren) listed above is 6 or older, is the indicated expense for Before or After school

care? Yes

If no, please explain__________________________________________________________

__________________________________________________________________________

__________________________

_________

__________________________

Student’s Signature

Date

Student’s SID

__________________________

_________

Spouse’s Signature

Date

*PLEASE NOTE: THIS FORM WILL NOT BE ACCEPTED WITHOUT RECEIPTS AND

LETTER FROM DAYCARE OR CAREGIVER (NOTARIZED, IF CAREGIVER).*

Disclosure of your social security number (SSN) is requested from you in order for The University of Texas Southwestern

Medical Center to verity your identity. No statute or other authority requires that you disclose your SSN for that purpose.

Failure to provide your SSN, however, may result in the inability to properly process your financial aid and may result in

delays. Further disclosure of your SSN is governed by the Public Information Act (Chapter 552 of the Texas Government

Code) and other applicable law.

With few exceptions, you are entitled on your request to be informed about the information U.T. Southwestern collects about you. Under Sections 552.021 and 552.023 of the

Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have U.T.

Southwestern correct information about you that is held by us and that is incorrect, in accordance with the procedures set forth in the University of Texas System Business

Procedures Memorandum 32. The information that U.T. Southwestern collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et

seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.