EXHIB B_OPM Form 1643.pdf

(Insert name of organization administering the program)

Section I - Parent / Legal Guardian Information

Section II - Child Information

1. Name (Last, first, middle initial) 2. Social Security Number (SSN) 3. Grade

4. Work address (Include street number, city, state and ZIP code) 5. Work e-mail address

6. Work telephone number

7. Home address (Include street number, city, state and ZIP code) 8. Home e-mail address

9. Home telephone number

Category of parent

Single

Couple

Spouse federal employee

13. Employing agency of spouse

12. Name of spouse (Last, first, middle initial)

Yes

No

CHILD CARE SUBSIDY APPLICATION FORM

The department may contact the applicant to request clarification on the subsidy application.

DEPARTMENT

You must attach the following documents:

1. Pay statements for the most recent two pay periods for each parent or guardian;

2. A copy of your most recent Federal and State income tax returns;

3. A copy of your child care provider's most recent license or statement of compliance with State and/or local child care regulations; and

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. 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.

15. Total family income as reported on adjusted gross income line of most recent IRS form 1040/1040A

*Include a copy of the IRS form

10. 11.

14. Grade of spouse

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)

1a. Name of first child c. Date of birth (MM/DD/YYYY)b. SSN of child

e. Weekly child care cost Date of enrollment (MM/DD/YYYY)

g. Type of application (Check one)

New family

Is any other form of State, County or Local subsidy being received for the child(ren)?

Yes (If "Yes", complete i. and j.)

No

Annual recertification

Adding/changing family information

Changing provider information (attach new license and OPM Form 1644)

Reapplication (previously enrolled, not current)

i. Source of subsidy

j. Amount of subsidy

d. Name of child care provider

k. Address of provider (Include street number, city, state and ZIP code) l. Telephone number of child care provider

Type of care (Check one)

Center-based care

Family home-based care

Office of Personnel Management Form authorized for local reproduction OPM 1643 Revised May 2003 f.

h.

m.

(Insert Federal Agency Name)

4. A completed OPM form 1644, signed by the provider(s) below.

Section III - Signature of Parent / Legal Guardian

2a. Name of second child c. Date of birth (MM/DD/YYYY)b. SSN of child

e. Weekly child care cost Date of enrollment (MM/DD/YYYY)

g. Type of application (Check one)

New family

Is any other form of State, County or Local subsidy being received for the child(ren)?

No

Annual recertification

Adding/changing family information Reapplication (previously enrolled, not current)

i. Source of subsidy

j. Amount of subsidy

d. Name of child care provider

Center-based care

Family home-based care

l. Telephone number of child care provider

Type of care (Check one)

Section II - Child Information (Continued)

3a. Name of third child b. SSN of child

e. Weekly child care cost

g. Type of application (Check one)

New family

Is any other form of State, County or Local subsidy being received for the child(ren)?

No

Annual recertification

Adding/changing family information Reapplication (previously enrolled, not current)

i. Source of subsidy

j. Amount of subsidy

d. Name of child care provider

Center-based care

Family home-based care

l. Telephone number of child care provider

Type of care (Check one)

I understand that it is a Federal crime under United States Code 18, Section 1001, to make a false statement on this form. If I make a false statement, I agree to be subject to criminal prosecution and punishment including a fine, imprisonment, or both. In addition, I may be subject to administrative punishment, including the termination of my federal employment.

I certify that the above information is true and correct to the best of my knowledge.

Signature Date of signature (MM/DD/YYYY)

Public Law 107-67, § 630 (September, 2001) confers regulatory authority on OPM 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 slips 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.

Privacy Act Statement

k. Address of provider (Include street number, city, state and ZIP code)

k. Address of provider (Include street number, city, state and ZIP code)

c. Date of birth (MM/DD/YYYY)

Date of enrollment (MM/DD/YYYY)

OPM 1643 (Back) Revised May 2003 f.

h.

Yes (If "Yes", complete i. and j.)

Yes (If "Yes", complete i. and j.)

m.

f.

h.

m.

Changing provider information (attach new license and OPM Form 1644)

Changing provider information (attach new license and OPM Form 1644)