Fillable Printable VA Form 0730i
Fillable Printable VA Form 0730i
VA Form 0730i
OMB Number: 2900-0717
Respondent Burden: 10 minutes
CHANGE IN CHILD CARE PROVIDER
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 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 (SSN) and tax identification numbers will be for identification purposes in assuring licensure 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 denial of your application.
RESPONDENT BURDEN - Public reporting burden for this collection of information is estimated to average 10 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 (005E3), 810 Vermont
Avenue, NW, Washington, DC 20420. DO NOT send requests for benefits to this address.
INSTRUCTION: This information is required by law for the agency administrator of the Child Care Subsidy Program to verify licensure status. Please complete this
form each time you change your child care provider. Mail completed form to: Department of Veterans Affairs, VA Child Care Subsidy Program Office (05CCSP), 810
Vermont Ave., NW, Washington, DC 20420.
PART I - PARENT INFORMATION
1. NAME OF PARENT/LEGAL GUARDIAN WITH CHILD
IN PROVIDER'S CARE
2. NAME OF VA CENTER OF PARENT
PART II - PROVIDER INFORMATION
3. CURRENT CHILD CARE PROVIDER 4. PREVIOUS CHILD CARE PROVIDER
5. ADDRESS OF CURRENT CHILD CARE PROVIDER
(Include street number, city, state, ZIP Code)
6. ADDRESS OF PREVIOUS CHILD CARE PROVIDER
(Include street number, city, state, ZIP Code)
7. TYPE OF PROVIDER (Check only one)
CENTER BASED
FAMILY CHILD CARE HOME
8. CHILD CARE SERVICES (Check only one)
FULL-TIME CARE
BEFORE SCHOOL CARE
AFTER SCHOOL CARE
BEFORE AND AFTER SCHOOL CARE
9. NEW CHILD CARE PROVIDER TELEPHONE NUMBER 10. CURRENT CHILD CARE PROVIDER E-MAIL ADDRESS 11. NEW CHILD CARE PROVIDER LICENSED
YES NO
12. TAX IDENTIFICATION NO. OR SOCIAL
SECURITY NO.
13. LICENSE NUMBER OF PROVIDER 14. STATE LICENSE ISSUED 15. LICENSE EXPIRATION DATE
(MM/DD/YYYY)
PART III - CHILD INFORMATION
INSTRUCTIONS: SCHEDULE OF FEES ATTACHED: DID THE PROVIDER COMPLETE THE SF 3881:
YES NO YES NO
A. NAME OF EACH CHILD ENROLLED
(Last, first, middle initial)
B. ENROLLMENT
DATE
(MM/DD/YYYY)
C. DOES THE
CHILD RECEIVE ANY
OTHER SUBSIDY? (If
"YES," complete D and E.)
YES
NO
D. SOURCE OF SUBSIDY
E. AMOUNT OF
SUBSIDY
$
F. TOTAL WEEKLY
FEE FOR CHILD
$
$ $
$ $
PART IV - CERTIFICATION AND SIGNATURE OF PROVIDER
CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge. I understand that it is a Federal crime under
United States Code 18, Section 1001, to make a false statement on this form. If I make a false statement, I agree to be subject to criminal prosecution
and punishment including a fine, imprisonment, or both.
16. NAME OF PROVIDER 17. SIGNATURE OF PROVIDER 18. SIGNATURE OF EMPLOYEE 19. DATE SIGNED
(MM/DD/YYYY)
VA FORM
JUN 2014
0730i
