Fillable Printable Opm1643
Fillable Printable Opm1643
Opm1643
SAMPLE
Child Care Tuition Assistance Application Form
Depar tment X
The (insert name of organization administering the program) may contact th e applicant t o
request clarification on the tuition assistance application. You must attach the following
documents:
1. P ay statements for the most recent 2 pay period s for each parent or guardian;
2. A copy of your most recent Federal and S tate income tax r etur ns; and
3. A copy of your child car e pr ovid er ’ s most recent license or statement of compliance
with State and/or local child care r egulations.
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 req uest ed , you wi ll no t receive a t u ition assist an ce award . Wh en more th an
one parent works for 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:
______________________________________________________________________________
______________________________________________________________________________
Work Phone: ________________________________ Grade (if Federal) : ________________
Father/guardian: ____________________________________ Home Phone:_______________
Address: _____________________________________________________________________
______________________________________________________________________________
Employer’s Na me & Address:
______________________________________________________________________________
______________________________________________________________________________
Work Phone: ________________________________ Grade (if Federal) : ________________
OPM Form 1643
March 2000
Application is being made for 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 _____
OPM Form 1643
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 annual salary of mother or guardian:
$_________________
Gross annual salary of father or guardian:
$_________________
Total gross family income (as reported on most recen t IRS tax return ):
$_________________
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 is the 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:
$____________
OPM Form 1643
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 our knowledge. 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 of the 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 that failure to inform ___________________________
Name of Organization
of any changes in st at us may jeopard i ze our chan ces of receivin g t u it i on assist an ce t h rou gh
Department X’s tuition assistance program.
Signature of Mother/Guardian _______________________________ Dat e_______________
Signature of Father/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 most recen t license or st at ement of compliance with St at e and /or lo cal
regulations.
Privacy Act St at ement
Public Law 106-58, Section 643 (September 29, 1999) confers regulatory author ity on OPM for
agency use of appropriated funds for child care costs for lower income Federal employees.
Public Law 104-134 (April 26, 1996) r equir es that any person doing business with the Federal
Government furnish a Social S ecurity Number or tax identification number. This is an
amendment to title 31, Section 7701. T he pr imary use of these Social Security Numbers will be
for identification purposes in determining eligibil ity for child car e tuition assistance. The
primary use of information regarding family income (copies of pay slips and tax returns), name
of current child care prov ider, copies of the provider’s license, statement of compliance, and
information about other child care subsidies is als o used to determine eligibility for child care
tuition assistance. Disclosure of the above information is voluntary, but failure t o provide all of
the requested information may r esult in denial of your application.
OPM Form 1643
March 2000
