Fillable Printable Child Care Rebate Application Form
Fillable Printable Child Care Rebate Application Form
Child Care Rebate Application Form
08-229 (0315-1540) (Page 1 of 2)
Application for Child Care Benefit for 24 hour care beyond
14 periods per financial year
A family may receive 24 hour care in a Child Care Benefit approved child care service (excluding occasional
care services) when because of work-related commitments or exceptional circumstances neither parent (or
the single parent) is available to care for the child for a period of 24 hours.
Child Care Benefit approved child care services have discretion to approve up to 14 periods of 24 hour care
for a child in a financial year (e.g.1 July 2015 — 30 June 2016). After 14 periods of 24 hour care are used,
this form must be completed as soon as possible and in advance of further 24 hour care being provided,
and forwarded to the Special Child Care Assistance Team in the Department of Human Services. They can
be contacted on 1800 050 021, or by fax to 1800 700 533.
1 Customer details
Family name ____________________________________
Given names ____________________________________
Home address ____________________________________
____________________________________ Postcode _________
Home telephone number ( ) ___________________________
Work telephone number ( ) ___________________________
Customer Reference Number (CRN) ___________________________
2 Child details
Child 1 Child 2 Child 3 Child 4
Family name _____________ _____________ _____________ _____________
Given names _____________ _____________ _____________ _____________
Child CRN _____________ _____________ _____________ _____________
If 24 hour care is being sought for more than 4 children, please attach a separate sheet with the above details.
3 Care required
Please provide detailed information about the reason(s) 24 hour care is required.Please attach a separate sheet if
insufficient space.
Note: The bottom one-quarter of Page 1 has been left blank here for you to provide your detailed information.
08-229 (0315-1540) (Page 2 of 2)
4 24 hour care periods required
Please provide information about the number of 24 hour care periods required (covered by this application), and dates:
Number of periods required: __________
Dates: from / / to / /
from / / to / /
from / / to / /
5 Parent statement
I declare that the information I have provided on this form is correct to the best of my knowledge.
I understand that the Department of Human Services will release information necessary to administer my
Child Care Benefit and/or Child Care Rebate to my child care service(s) and the Department of Social Services.
I understand there are penalties for giving false or misleading information.
Signature __________________________________Date/ /
What to do next?
When the form is fully completed and signed give it to your service.
Your service will forward your application to theSpecial Child Care Assessment Team in the Department of
Human Services
When your application has been assessed your service will be notified of the result, and you will be advised if the
application has been approved.
Families who require translating and/or interpreting assistance should call the Department of Human Services
Multilingual Telephone Service on 131 202.
Service to complete
Service details
Service name ___________________________________________________________
Service CCB Approval ID ___________________________________________________________
Service address ____________________________________
____________________________________ Postcode _________
Service telephone number ( ) _____________________________
Name of contact person _____________________________
Department of Human Services use only
I, ________________________________,
Please clearly print name
acting under authorised delegation for the Secretary for the Department ofSocial Services. Approve this application for
Child Care Benefit 24 hour care for the child(ren) named in this application.
Approval is granted for the period between / / to / /
Do not approve this application for 24 hour care as the reasons specified are not consistent with those for which
approval may be made.
Signature __________________________________ Date/ /
Position in organisation
