Form 0730a Child Care Subsidy Application Form

OMB Number: 2900-0717
Respondent Burden: 20 minutes

CHILD CARE SUBSIDY APPLICATION FORM
PRIVACY ACT STATEMENT - Public Law 107-67, § 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. 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

4. ORGANIZATIONAL CODE (See list
of codes at bottom of Section I)

3. JOB SERIES/GRADE

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

12. IS SPOUSE A
FEDERAL EMPLOYEE?

SINGLE

YES

COUPLE

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)
(00CFM)
(002)
(004A)
(004G)
(004F)
(004S)
(005G)
(005F)
(006G)
(007)

Office of the Secretary
Assistant Secretary for Construction & Facilities Management
Assistant Secretary for Public & Intergovernmental Affairs
Assistant Secretary for Management (Finance Fund)
Assistant Secretary for Management (GOE)
Assistant Secretary for Management (Franchise Fund)
Assistant Secretary for Management (Supply Fund)
Assistant Secretary for Information & Technology (GOE)
Assistant Secretary for Information & Technology (Franchise Fund)
Assistant Secretary for Human Resources & Administration (GOE)
Assistant Secretary for Operations, Security and Preparedness

(008)
(009)
(01)
(02)
(10M)
(10F)
(10R)
(10E)
(10C)
(20)
(40)
(50)

Assistant Secretary for Policy and Planning
Assistant Secretary for Congressional & Legislative Affairs
Board of Veterans' Appeals
General Counsel
Veterans Health Administration - Medical Services
Veterans Health Administration - Medical Facilities
Veterans Health Administration - Research
Veterans Health Administration - Medical Administration
Veterans Health Administration - Canteen Service
Veterans Benefits Administration
National Cemetery Administration
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.)
1B. DATE OF BIRTH (MM/DD/YYYY)

1A. NAME OF FIRST CHILD

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.)

1G. ENTER LAST DAY WITH PREVIOUS
PROVIDER (MM/DD/YYYY)

CHANGING PROVIDER INFORMATION
(Complete Item 1H)
(Attach license, schedule of fees, and VA Form 0730b.)

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
NO
award letter.)
1K. ADDRESS OF PROVIDER (Include street number, city, state and ZIP Code)

1I. SOURCE OF SUBSIDY

1L. TELEPHONE NUMBER
OF CHILD CARE PROVIDER

1J. AMOUNT OF SUBSIDY

$
1M. TYPE OF CARE (Check one)
CENTER-BASED

VA-BASED

FAMILY HOME-BASED

SCHOOL-BASED

OTHER
VA FORM
FEB 2009

0730a

SUPERSEDES VA FORM 0730a, DATED APR 2008, WHICH
MAY NOT BE USED.

Adobe LiveCycle Designer 7.1

SECTION II - CHILD INFORMATION (Continued)
2B. DATE OF BIRTH (MM/DD/YYYY)

2A. NAME OF SECOND CHILD

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)

2G. ENTER LAST DAY WITH PREVIOUS
PROVIDER (MM/DD/YYYY)

REAPPLICATION (Previously enrolled, not current.)

NEW FAMILY
ANNUAL RECERTIFICATION
ADDING/CHANGING FAMILY INFORMATION

CHANGING PROVIDER INFORMATION
(Complete Item 1H)
(Attach license, schedule of fees, and VA Form 0730b.)

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
NO
award letter.)

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

VA-BASED

FAMILY HOME-BASED

SCHOOL-BASED

OTHER

3B. DATE OF BIRTH (MM/DD/YYYY)

3A. NAME OF THIRD CHILD

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)
REAPPLICATION (Previously enrolled, not current.)

NEW FAMILY
ANNUAL RECERTIFICATION
ADDING/CHANGING FAMILY INFORMATION

3G. ENTER LAST DAY WITH PREVIOUS
PROVIDER (MM/DD/YYYY)

CHANGING PROVIDER INFORMATION
(Complete Item 1H)
(Attach license, schedule of fees, and VA Form 0730b.)

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.)

3I. SOURCE OF SUBSIDY

3J. AMOUNT OF SUBSIDY

$

NO

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

VA-BASED

FAMILY HOME-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, FEB 2009, PAGE 2