Fillable Printable VA Form 0730h

VA Form 0730h

VA CHILD CARE SUBSIDY PROGRAM

BENEFIT PAYMENT REQUEST FORM

PRIVACY ACT STATEMENT - Public Law 107-67, Section 630 (November 12, 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 furnishes 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 (SSN) and tax identification numbers will be for identification purposes in assuring

licensure and/or regulation compliance. This compliance is necessary for the purpose of determining Federal employee eligibility for child care subsidy.

Disclosure of the above information is voluntary, but failure to provide all of the requested information may result in the denial of your request for

payment of child care subsidy benefits.

INSTRUCTIONS: Employees approved to participate in the VA Child Care Subsidy Program (CCSP) must use this form to request monthly child care

subsidy benefits payments. A separate form must be prepared for each month benefits are requested and should not be submitted until child care services

for the month have been provided. Employees are responsible for ensuring the information provided on the Child Care Records Management System

(CCRMS) on-line benefit payment request matches information on invoices before submission to the CCSP Service for payment.

Benefits payment requests must be submitted through the CCRMS not later than the second Friday of the month following the month for which a benefit

payment is requested. For example, if payment is requested for June, the invoice must be received not later than the second Friday of July of the same

year. Invoices that are not received within the required timeframe will not be paid. Exceptions to this timeframe will not be approved for any

reason. Mailed, faxed or emailed submissions will not be accepted. The child care provider's invoice should include the name of the provider

or company, invoice number, the provider's Federal tax identification number, a description of services, and total cost of monthly services.

NOTE: You are responsible for the payment of your total child care cost and must pay the full amount on all invoices issued to you by your child care

provider. As a participant in the VA Child Care Subsidy Program, you are eligible to receive a subsidy to be applied towards your child care costs. Your

monthly child care subsidy will be forwarded to your child care provider on your behalf. Any arrangement you make with your provider regarding the

manner in which your child care subsidy benefits are credited to your account is between you and your child care provider.

SECTION I - PARENT/LEGAL GUARDIAN INFORMATION

1. NAME AND HOME ADDRESS OF EMPLOYEE

(Include Street Number, City, State and ZIP Code)

2. HOME PHONE NUMBER

3. HOME E-MAIL ADDRESS (If applicable)

4. WORK ADDRESS (Include Street Number,

City, State and ZIP Code)

5. WORK PHONE NUMBER

6. STATION NUMBER

7. WORK E-MAIL ADDRESS (If applicable)

SECTION II - CHILD CARE PROVIDER INFORMATION

1. NAME AND ADDRESS OF CHILD CARE PROVIDER/COMPANY (Include Street Number,

City, State and Zip Code)

2. TELEPHONE NUMBER OF CHILD CARE PROVIDER

3. E-MAIL ADDRESS OF CHILD CARE PROVIDER

4a. CHILD'S NAME: AGE:

4b. CHILD'S NAME: AGE:

4c. CHILD'S NAME: AGE:

4d. CHILD'S NAME: AGE:

5. INDICATE THE MONTH AND YEAR FOR WHICH YOU ARE REQUESTING A SUBSIDY FOR CHILD CARE PROVIDER COSTS (MONTH/YEAR) /

6. INDICATE BELOW THE FULL CHILD CARE COST FOR EACH WEEK OF THE MONTH YOU ARE REQUESTING A CHILD CARE SUBSIDY BENEFIT

WEEK 1 ENDING DATE: WEEK 2 ENDING DATE: WEEK 3 ENDING DATE: WEEK 4 ENDING DATE: WEEK 5 ENDING DATE:

WEEK 1 TOTAL CHARGES:

WEEK 2 TOTAL CHARGES:

WEEK 3 TOTAL CHARGES:

WEEK 4 TOTAL CHARGES:

WEEK 5 TOTAL CHARGES:

MONTHLY TOTAL:

SECTION III - CERTIFICATION AND SIGNATURE OF EMPLOYEE

CERTIFICATION: I certify that the above information is true and correct and that the above child care services were received for the period of time

this request covers. I understand that failure to truthfully set forth this information could result in the loss of child care subsidy from the Department of

Veterans Affairs.

Employee's Signature Date of Signature (MM/DD/YYYY)

SECTION IV - FOR APPROVING OFFICE USE ONLY

MONTHLY COST:

VA PERCENTAGE: SUBSIDY AMOUNT:

DISAPPROVED

EXPLANATION:

AUTHORIZING OFFICIAL SIGNATURE: DATE:

COMMENT: DATE PAID: INVOICE NUMBER:

VA FORM

JUN 2014

0730h