Fillable Va 0730a Child Care Subsidy Application Form (Page 2 of 2) in pdf

SECTION II - CHILD INFORMATION (Continued)

2A. NAME OF SECOND CHILD

2B. DATE OF BIRTH (MM/DD/YYYY)

2C. NAME OF CHILD CARE PROVIDER

2D. WEEKLY CHILD CARE COST

2E. DATE OF ENROLLMENT (MM/DD/YYYY)

2F. TYPE OF APPLICATION? (Check only one)

2G. ENTER LAST DAY WITH PREVIOUS

PROVIDER (MM/DD/YYYY)

NEW FAMILY

REAPPLICATION (Previously enrolled, not current.)

ANNUAL RECERTIFICATION

CHANGING PROVIDER INFORMATION

(Complete Item 1H)

ADDING/CHANGING FAMILY INFORMATION

(Attach license, schedule of fees, and VA Form 0730b.)

2H. IS ANY OTHER FORM OF STATE, COUNTY OR LOCAL SUBSIDY BEING

2I. SOURCE OF SUBSIDY

2J. AMOUNT OF SUBSIDY

RECEIVED FOR THE CHILD(REN)?

YES (If "YES," complete items 2J and 2K and submit a copy of

award letter.)

2K. ADDRESS OF PROVIDER (Include street number, city, state and ZIP Code) 2L. TELEPHONE NUMBER OF

2M. TYPE OF CARE (Check one)

CHILD CARE PROVIDER

CENTER-BASED

VA-BASED

FAMILY HOME-BASED

SCHOOL-BASED

OTHER

3A. NAME OF THIRD CHILD

3B. DATE OF BIRTH (MM/DD/YYYY)

3C. NAME OF CHILD CARE PROVIDER

3D. WEEKLY CHILD CARE COST

3E. DATE OF ENROLLMENT (MM/DD/YYYY)

3F. TYPE OF APPLICATION? (Check only one)

3G. ENTER LAST DAY WITH PREVIOUS

PROVIDER (MM/DD/YYYY)

NEW FAMILY

REAPPLICATION (Previously enrolled, not current.)

ANNUAL RECERTIFICATION

CHANGING PROVIDER INFORMATION

(Complete Item 1H)

ADDING/CHANGING FAMILY INFORMATION

(Attach license, schedule of fees, and VA Form 0730b.)

3H. IS ANY OTHER FORM OF STATE, COUNTY OR LOCAL SUBSIDY BEING

3I. SOURCE OF SUBSIDY

3J. AMOUNT OF SUBSIDY

RECEIVED FOR THE CHILD(REN)?

YES (If "YES," complete items 3J and 3K and submit a copy of

award letter.)

3K. ADDRESS OF PROVIDER (Include street number, city, state and ZIP Code) 3L. TELEPHONE NUMBER OF

3M. TYPE OF CARE (Check one)

CHILD CARE PROVIDER

CENTER-BASED

VA-BASED

FAMILY HOME-BASED

SCHOOL-BASED

OTHER

SECTION III - SIGNATURE AND CERTIFICATION OF PARENT/LEGAL GUARDIAN

I certify that the above information is true and complete to the best of my knowledge. I understand that failure to truthfully set forth

this information could result in loss of child care subsidy from the Department of Veterans Affairs. I further agree to inform my

local Human Resources (HR) office within 10 days if any of the above information changes. I understand that awards for child care

subsidy are made on a first-come, first-served basis. I understand that failure to inform my local HR office of any changes in status

may jeopardize my chances of receiving child care subsidy through the Department of Veterans Affairs Child Care Subsidy Program.

If I answered "YES," in Part I, block 12, I certify that my spouse has not applied for a child care subsidy from his/her Federal agency.

(Signature)

(Date of signature (MM/DD/YYYY))

RESPONDENT BURDEN - Public reporting burden for this collection of information is estimated to average 20 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 aspects of this collection, including suggestions for reducing this burden, to the VA Clearance Officer (005R1B),

810 Vermont Avenue, NW, Washington, DC 20420. DO NOT send requests for benefits to this address.

VA FORM 0730a, AUG 2012, PAGE 2