Fillable Printable VA Form 0730a
Fillable Printable VA Form 0730a
VA Form 0730a
OMB Number: 2900-0717
Respondent Burden: 20 minutes
CHILD CARE SUBSIDY APPLICATION FORM
PRIVACY ACT STATEMENT - Public Law 107-67, ยง 630 (September 2001) confers regulatory authority on the Department of Veterans Affairs 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 statements 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.
SECTION I - PARENT/LEGAL GUARDIAN INFORMATION
NOTE: 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 through the
submitting HR office. 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.
1. NAME (Last, first, middle initial) 2. SOCIAL SECURITY NUMBER 3. JOB SERIES/GRADE 4. ORGANIZATIONAL CODE (See list
of codes at bottom of Section I)
5. WORK ADDRESS (Include street number, city, state and ZIP Code) 6. WORK E-MAIL ADDRESS
7. WORK TELEPHONE NUMBER/EXTENSION
8. HOME ADDRESS (Include street number, city, state and ZIP Code) 9. HOME E-MAIL ADDRESS
10. HOME TELEPHONE NUMBER
11. CATEGORY OF
PARENT
SINGLE
COUPLE
12. IS SPOUSE A
FEDERAL EMPLOYEE?
YES
NO
13. NAME OF SPOUSE (Last, first, middle initial) 14. GRADE OF SPOUSE
15. EMPLOYING AGENCY OF SPOUSE
16. TOTAL FAMILY INCOME AS REPORTED ON ADJUSTED GROSS INCOME LINE OF MOST RECENT IRS FORM 1040 OR 1040A.
$
ORGANIZATIONAL CODES
(00) Office of the Secretary
(00CFM) Assistant Secretary for Construction & Facilities Management
(002) Assistant Secretary for Public & Intergovernmental Affairs
(003) Office of Acquisition, Logistics & Construction
(004A) Assistant Secretary for Management (Finance Fund)
(004G) Assistant Secretary for Management (GOE)
(004F) Assistant Secretary for Management (Franchise Fund)
(005G) Assistant Secretary for Information & Technology (GOE)
(005F) Assistant Secretary for Information & Technology (Franchise Fund)
(006E) Corporate Senior Executive Management Office
(006G) Assistant Secretary for Human Resources & Administration (GOE)
(007) Assistant Secretary for Operations, Security and Preparedness
(008) Assistant Secretary for Policy and Planning
(009) Assistant Secretary for Congressional & Legislative Affairs
(01) Board of Veterans' Appeals
(02) General Counsel
(10M) Veterans Health Administration - Medical Services
(10F) Veterans Health Administration - Medical Facilities
(10R) Veterans Health Administration - Research
(10E) Veterans Health Administration - Medical Administration
(10C) Veterans Health Administration - Canteen Service
(20) Veterans Benefits Administration
(40) National Cemetery Administration
(50) Inspector General
SECTION II - CHILD INFORMATION
INSTRUCTION: 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 1B. DATE OF BIRTH (MM/DD/YYYY)
1C. NAME OF CHILD CARE PROVIDER 1D. WEEKLY CHILD CARE COST
$
1E. DATE OF ENROLLMENT (MM/DD/YYYY)
1F. TYPE OF APPLICATION? (Check only one)
NEW FAMILY
ANNUAL RECERTIFICATION
ADDING/CHANGING FAMILY INFORMATION
REAPPLICATION (Previously enrolled, not current.)
CHANGING PROVIDER INFORMATION
(Complete Item 1H)
(Attach license, schedule of fees, and VA Form 0730b.)
1G. ENTER LAST DAY WITH PREVIOUS
PROVIDER (MM/DD/YYYY)
1H. IS ANY OTHER FORM OF STATE, COUNTY OR LOCAL SUBSIDY BEING
RECEIVED FOR THE CHILD(REN)?
YES (If "YES," complete items 1J and 1K and submit a copy of
award letter.)
NO
1I. SOURCE OF SUBSIDY 1J. AMOUNT OF SUBSIDY
$
1K. ADDRESS OF PROVIDER (Include street number, city, state and ZIP Code) 1L. TELEPHONE NUMBER
OF CHILD CARE PROVIDER
1M. TYPE OF CARE (Check one)
CENTER-BASED
FAMILY HOME-BASED
VA-BASED
SCHOOL-BASED
OTHER
VA FORM
AUG 2012
0730a
SUPERSEDES VA FORM 0730a, DATED JUN 2010, WHICH
MAY NOT BE USED.
SECTION II - CHILD INFORMATION (Continued)
2A. NAME OF SECOND CHILD 2B. DATE OF BIRTH (MM/DD/YYYY)
2C. NAME OF CHILD CARE PROVIDER 2D. WEEKLY CHILD CARE COST
$
2E. DATE OF ENROLLMENT (MM/DD/YYYY)
2F. TYPE OF APPLICATION? (Check only one)
NEW FAMILY
ANNUAL RECERTIFICATION
ADDING/CHANGING FAMILY INFORMATION
REAPPLICATION (Previously enrolled, not current.)
CHANGING PROVIDER INFORMATION
(Complete Item 1H)
(Attach license, schedule of fees, and VA Form 0730b.)
2G. ENTER LAST DAY WITH PREVIOUS
PROVIDER (MM/DD/YYYY)
2H. IS ANY OTHER FORM OF STATE, COUNTY OR LOCAL SUBSIDY BEING
RECEIVED FOR THE CHILD(REN)?
YES (If "YES," complete items 2J and 2K and submit a copy of
award letter.)
NO
2I. SOURCE OF SUBSIDY 2J. AMOUNT OF SUBSIDY
$
2K. ADDRESS OF PROVIDER (Include street number, city, state and ZIP Code) 2L. TELEPHONE NUMBER OF
CHILD CARE PROVIDER
2M. TYPE OF CARE (Check one)
CENTER-BASED
FAMILY HOME-BASED
VA-BASED
SCHOOL-BASED
OTHER
3A. NAME OF THIRD CHILD 3B. DATE OF BIRTH (MM/DD/YYYY)
3C. NAME OF CHILD CARE PROVIDER 3D. WEEKLY CHILD CARE COST
$
3E. DATE OF ENROLLMENT (MM/DD/YYYY)
3F. TYPE OF APPLICATION? (Check only one)
NEW FAMILY
ANNUAL RECERTIFICATION
ADDING/CHANGING FAMILY INFORMATION
REAPPLICATION (Previously enrolled, not current.)
CHANGING PROVIDER INFORMATION
(Complete Item 1H)
(Attach license, schedule of fees, and VA Form 0730b.)
3G. ENTER LAST DAY WITH PREVIOUS
PROVIDER (MM/DD/YYYY)
3H. IS ANY OTHER FORM OF STATE, COUNTY OR LOCAL SUBSIDY BEING
RECEIVED FOR THE CHILD(REN)?
YES (If "YES," complete items 3J and 3K and submit a copy of
award letter.)
NO
3I. SOURCE OF SUBSIDY 3J. AMOUNT OF SUBSIDY
$
3K. ADDRESS OF PROVIDER (Include street number, city, state and ZIP Code) 3L. TELEPHONE NUMBER OF
CHILD CARE PROVIDER
3M. TYPE OF CARE (Check one)
CENTER-BASED
FAMILY HOME-BASED
VA-BASED
SCHOOL-BASED
OTHER
SECTION III - SIGNATURE AND CERTIFICATION OF PARENT/LEGAL GUARDIAN
I certify that the above information is true and complete to the best of my knowledge. I understand that failure to truthfully set forth
this information could result in loss of child care subsidy from the Department of Veterans Affairs. I further agree to inform my
local Human Resources (HR) office within 10 days if any of the above information changes. I understand that awards for child care
subsidy are made on a first-come, first-served basis. I understand that failure to inform my local HR office of any changes in status
may jeopardize my chances of receiving child care subsidy through the Department of Veterans Affairs Child Care Subsidy Program.
If I answered "YES," in Part I, block 12, I certify that my spouse has not applied for a child care subsidy from his/her Federal agency.
(Signature) (Date of signature (MM/DD/YYYY))
RESPONDENT BURDEN - Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspects of this collection, including suggestions for reducing this burden, to the VA Clearance Officer (005R1B),
810 Vermont Avenue, NW, Washington, DC 20420. DO NOT send requests for benefits to this address.
VA FORM 0730a, AUG 2012, PAGE 2
