CHILD CARE PROVIDER INFORMATION
(For the Child Care Subsidy Program)
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 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 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.
INSTRUCTIONS:
Employees approved to participate in the VA Child Care Subsidy Program must use this form to request monthly child care subsidy benefit payments. An invoice from the child care provider
must be prepared indicating the total cost of daycare and uploaded into the Child Care Record Management System (CCRMS) each month benefits are requested. The child care provider's
invoice should include the name and address of the provider or company, the provider's Federal tax identification number, a description of services and the total cost of monthly services.
Request for benefits should be uploaded into CCRMS by the 15th of each month unless the date falls on a weekend and/or holiday then the submission deadline will move to the following
business day.
NOTE:
As a participant in the VA Child Care Subsidy Program, you are eligible to receive a subsidy to be applied towards your child care cost. Your monthly child care subsidy will be forwarded to
your child care provider on your behalf. However, 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, if no VA CCSP benefit credit is available on your account. Any arrangement you make with your provider regarding how your child care subsidy benefits are credited and/or any
payment arrangements on your account is between you and your child care provider.
PART I - PARENT INFORMATION
1. NAME OF PARENT/LEGAL GUARDIAN WITH CHILD IN THE
PROVIDER'S CARE
2. FEDERAL AGENCY OF PARENT
Department of Veterans Affairs
PART II - PROVIDER INFORMATION
1. TYPE OF PROVIDER (Check only one)
CENTER BASED FAMILY HOME BASED CARE VA CHILD CENTER
SCHOOL-BASED CARE
OTHER FEDERAL CHILD CARE
2. CHILD CARE SERVICES (Check only one)
FULL-TIME CARE BEFORE SCHOOL CARE
AFTER SCHOOL CARE BEFORE AND AFTER SCHOOL CARE
3. NAME OF CHILD CARE PROVIDER
4. ADDRESS OF CHILD CARE PROVIDER (Include street number, city, state, ZIP Code)
5. PROVIDER E-MAIL ADDRESS
6. PROVIDER TELEPHONE NUMBER
7. TAX IDENTIFICATION NO. OR
SOCIAL SECURITY NO.
8. PROVIDER FAX NUMBER 9. LICENSE NUMBER OF
PROVIDER
10. STATE IN WHICH LICENSE
IS ISSUED
11. LICENSE EXPIRATION DATE
(MM/DD/YYYY)
PART III - CHILD INFORMATION
INSTRUCTION: Please furnish the information below and attach a copy of your latest license and/or regulatory document and schedule of fees.
A. NAME OF EACH CHILD IN SECTION I
PARENT'S FAMILY 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.
1. NAME OF PROVIDER 2. TITLE OF PROVIDER REPRESENTATIVE 3. SIGNATURE OF PROVIDER (Ink signature) 4. DATE SIGNED
(MM/DD/YYYY)
VA FORM
JUL 2021
0730b
Supersedes VA Form 0730b, JUL 2007,
which will not be used.
