EXHIB B_OPM form 1644.pdf

Section II - Provider Information

Section I - Parent Information

Section III - Child Information

This information is required by law for the agency administrator of the Child Care Subsidy Program to verify licensure and/or regulation status. Once you are notified by a Federal employee that they submitted an application for child care subsidy from their Federal agency, please complete this form and return it to the parent.

Office of Personnel Management Form authorized for local reproduction OPM 1644 Revised May 2003

CHILD CARE PROVIDER INFORMATION FOR THE CHILD CARE SUBSIDY

PROGRAM FOR FEDERAL EMPLOYEES

1. Name of parent/legal guardian with child in the provider's care

Please furnish the information below for each Federal employee who applied for subsidy at your facility:

1. Type of provider (Check one)

Family Child Care Child Care Center Federally Sponsored Child Care Center

2. Name of child care provider

Address of child care provider (Include street number, city, state and ZIP code)3. 4. Provider e-mail address

5. Provider telephone number

7. Provider fax number6. Tax identification number or Social Security Number

8. License number of provider 9. State in which license is issued 10. License expiration date (MM/DD/YYYY)

(If "Yes", complete

d. and e.)

a. Name of each child in Section I parent's family enrolled (Last, first, middle initial)

b. Enrollment date

(MM/DD/YYYY)

c. Does the child receive any other subsidy?

Yes No

e. Amount of subsidy

d. Source of subsidy

f. Total weekly fee for child

Form Aproved:

OMB No. 3206-0240

2. Federal agency of parent

Section IV - Information on Provider's Financial Institution's Account for Payment to Provider (Used only by Agencies that Self-Administer the Program)

Section V - Signature of Provider

OPM 1644 (Back) Revised May 2003

Public Burden Statement

Public Law 106-554, § 633 (September 29, 2000) 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 and tax identification 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

We think this form takes an average of 10 minutes to complete including the time for getting the needed data and reviewing both the instructions and completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Reports and Forms Manager, Paperwork Reduction (3206-0240), Washington, DC 20415-7900. The OMB Number, 3206-0240, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

1. Name of financial institution

4. Type of account (For payment deposit) (Check one)

Checking

Savings

3. Address of financial institution (Include street number, city, state, and ZIP code)

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.

2. Financial institution's routing number

5. Provider's account number

1. Name of provider 2. Title of provider representative

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

4. Date of signature (MM/DD/YYYY)3.