Fillable Printable Opm1643
Fillable Printable Opm1643
Opm1643
SAMPLE
Child Care Tuition Assistance Application Form
Depar tment X
The (insert name oforganization administering the program) may contact th e applicant t o
request clarification on the tuition assistance application. Youmust attach thefollowing
documents:
1. P ay statements forthe mostrecent 2 pay period s for each parentor guardian;
2.A copyofyour mostrecentFederaland S tate income tax r etur ns;and
3.A copyofyour child car e pr ovid er ’ smost recent license or statementof compliance
with State and/or localchild care r egulations.
Applications that are notfully completed or do not contain the information listed below
will not be processed and will bereturned to the applicant.If you do not provide all of the
information req uest ed , you wi ll no t receive a t u ition assist an ce award . Wh en more th an
one parent worksfor the Federal Government, tuition assistance cannot be awarded for the
child/children by more than one Federal agency.
Mother/guardian: ___________________________________ Home Phone:_______________
Address: _____________________________________________________________________
______________________________________________________________________________
Employer’s Name and Address:
______________________________________________________________________________
______________________________________________________________________________
WorkPhone: ________________________________ Grade (ifFederal) : ________________
Father/guardian: ____________________________________ Home Phone:_______________
Address: _____________________________________________________________________
______________________________________________________________________________
Employer’s Na me & Address:
______________________________________________________________________________
______________________________________________________________________________
WorkPhone: ________________________________ Grade (ifFederal) : ________________
OPMForm1643
March 2000
Application is being madefor tuition assistance for:
Child: __________________________________________ Date of birt h: _________________
SSN: ___________________________________Weekly tuit ion cost: __________________
Enrolled now? ______________ Will be enrolled. Date of enrollment __________________
Child care provider: ___________________________________________________________
Address: _____________________________________________________________________
______________________________________________________________________________
Phone: _______________________ Center- based care _____ Family child care home _____
Child: __________________________________________ Date of birt h: _________________
SSN: ___________________________________Weekly tuit ion cost: __________________
Enrolled now? ______________ Will be enrolled. Date of enrollment __________________
Child care provider: ___________________________________________________________
Address: _____________________________________________________________________
______________________________________________________________________________
Phone: _______________________ Center- based care _____ Family child care home _____
Child: __________________________________________ Date of birt h: _________________
SSN: ___________________________________Weekly tuit ion cost: __________________
Enrolled now? ______________ Will be enrolled. Date of enrollment __________________
Child care provider: ___________________________________________________________
Address: _____________________________________________________________________
______________________________________________________________________________
Phone: _______________________ Center- based care _____ Family child care home _____
OPMForm1643
March 2000
Child: __________________________________________ Date of birt h: _________________
SSN: ___________________________________Weekly tuit ion cost: __________________
Enrolled now? ______________ Will be enrolled. Date of enrollment __________________
Child care provider: ___________________________________________________________
Address: _____________________________________________________________________
______________________________________________________________________________
Phone: _______________________ Center- based care _____ Family child care home _____
Family Inc ome :
Gross annualsalary ofmotheror guardian:
$_________________
Gross annualsalary offatheror guardian:
$_________________
Totalgross family income (as reported on most recen t IRS taxreturn ):
$_________________
State/County/Local Subsidies:
Do you currently receive an y t u it i on assist an ce from Stat e/Cou n t y/local ch i ld care su b sidy
funds? Yes
_____
No _____ If so, from what source?
________________________________
Address:______________________________________________________________________
______________________________________________________________________________
Contact person: _______________________________________________________________
What isthe weekly amount? $__________________
List t he amou nt an d n ame of each ch ild for wh om you recei ve t he S t at e/Count y /local
subsidy:
Name of child:
_______________________________
Daily subsidy amount:
$____________
Name of child:
_______________________________
Daily subsidy amount:
$____________
Name of child:
_______________________________
Daily subsidy amount:
$____________
Name of child:
_______________________________
Daily subsidy amount:
$____________
OPMForm1643
March 2000
I/We stat e t h at everythi ng we have st at ed in this app licat i on is t ru e an d correct t o t he b est
of ourknowledge. I/We understand that failure to truthfully set forth this information
could result i n loss of tuiti on assi stan ce from Department X. I/ We furth er agree to i n form
___________________________ within 10 days if any ofthe above information
Name of Organization
changes. I/We understand that application for tuition assistance is made on a first-come,
first-served basis. I/We understand thatfailure to inform ___________________________
Name of Organization
of any changes in st at us may jeopard i ze our chan ces ofreceivin g t u it i on assist an ce t h rou gh
Department X’s tuition assistance program.
Signature ofMother/Guardian _______________________________ Dat e_______________
Signature ofFather/Guardian _______________________________ Dat e_______________
Attached:
1.Pay statements for the most recent 2 pay period for each parent or guardian.
2.Most recen t Federal an d State in come tax forms.
3.Provid er’ s mostrecen t license or st at ement of compliance with St at e and /orlo cal
regulations.
Privacy Act St at ement
Public Law 106-58, Section 643 (September 29, 1999)confers regulatory author ityon OPMfor
agencyuse of appropriated funds for child care costsfor lower income Federalemployees.
Public Law 104-134 (April 26, 1996) r equir es that any person doing business withthe Federal
Governmentfurnish a Social S ecurity Number ortaxidentificationnumber. Thisis an
amendment to title 31, Section 7701. T he pr imaryuse ofthese Social Security Numbers willbe
foridentification purposes in determining eligibil ityfor child car e tuition assistance.The
primary use ofinformation regarding familyincome (copiesof pay slips and tax returns), name
of current child care prov ider, copies ofthe provider’slicense, statement of compliance, and
information aboutotherchild care subsidies is als oused todetermine eligibilityfor childcare
tuition assistance. Disclosure ofthe above informationisvoluntary, butfailure t o provide allof
the requested informationmay r esultin denialofyour application.
OPMForm1643
March 2000
