_________________________________________________________

Employers Name and Address: __________________________________________

_________________________________________________________

Work Phone: ________________________________

Grade (if Federal): ________________

Father/guardian:____________________________________ 

Home Phone:_______________

Address: _________________________________________________________

_________________________________________________________

Employers Name & Address: _________________________________________________________

Work Phone: ________________________________

Grade (if Federal): ________________

OPM Form 1643

March 2000

Application is being made for tuition assistance for:

Child: __________________________________________ 

Date of birth: _________________

SSN: ___________________________________ 

Weekly tuition cost: __________________

Enrolled now? ______________ 

Will be enrolled. Date of enrollment __________________

Child care provider: _________________________________________________________

Address: _________________________________________________________

_________________________________________________________

Phone: _______________________ Center-based care _____

Family child care home _____

Child: __________________________________________

Date of birth: _________________

SSN: ___________________________________

Weekly tuition cost: __________________

Enrolled now? ______________

Will be enrolled. Date of enrollment __________________

Child care provider: _________________________________________________________

Address: _________________________________________________________

_________________________________________________________

Phone: _______________________ Center-based care _____

Family child care home _____

Child: __________________________________________

Date of birth: _________________

SSN: ___________________________________ 

Weekly tuition cost: __________________

Enrolled now? ______________ 

Will be enrolled. Date of enrollment __________________

Child care provider: __________________________________________________________

Address: __________________________________________________________

__________________________________________________________

Phone: _______________________ Center-based care _____

Family child care home _____

OPM Form 1643

March 2000

Child: __________________________________________

Date of birth: _________________

SSN: ___________________________________

Weekly tuition cost: __________________

Enrolled now? ______________

Will be enrolled. Date of enrollment __________________

Child care provider: _________________________________________________________

Address: _________________________________________________________

_________________________________________________________

Phone: _______________________ Center-based care _____

Family child care home _____

Family Income:

Gross annual salary of mother or guardian: $_________________

Gross annual salary of mother or guardian: $_________________

Gross annual salary of mother or guardian:$_________________

Gross annual salary of father or guardian: $_________________

Total gross family income
(as reported on most recent IRS tax return): $_________________

State/County/Local Subsidies:

Do you currently receive any tuition assistance from State/County/local child care subsidy funds? Yes _____ No _____
If so, from what source? ________________________________

Address: _________________________________________________________

Contact person: _________________________________________________________

What is the weekly amount? $__________________

List the amount and name of each child for whom you receive the State/County/local subsidy:

Name of child: _______________________________

Daily subsidy amount: $____________

Name of child: _______________________________

Daily subsidy amount: $____________

Name of child: _______________________________

Daily subsidy amount: $____________

Name of child: _______________________________

Daily subsidy amount: $____________

OPM Form 1643

March 2000

I/We state that everything we have stated in this application is true and correct to the best of our knowledge. I/We understand that failure to truthfully set forth this information could result in loss of tuition assistance from Department X. I/We further agree to inform ___________________________ within 10 days if any of the above information

Name of Organization changes. I/We understand that application for tuition assistance is made on a first-come, first-served basis.

I/We understand that failure to inform ___________________________ Name of Organization of any changes in status may jeopardize our chances of receiving tuition assistance through Department Xs tuition assistance program.

Signature of Mother/Guardian _______________________________ Date_______________

Signature of Father/Guardian _______________________________ Date_______________

Attached:

1. Pay statements for the most recent 2 pay period for each parent or guardian.
2. Most recent Federal and State income tax forms.
3. Providers most recent license or statement of compliance with State and/or local regulations.

Privacy Act Statement

Public Law 106-58, Section 643 (September 29, 1999) confers regulatory authority on OPM 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 tuition assistance. The primary use of information regarding family income (copies of pay slips and tax returns), name of current child care provider, copies of the providers license, statement of compliance, and information about other child care subsidies is also used to determine eligibility for child care tuition assistance. Disclosure of the above information is voluntary, but failure to provide all of the requested information may result in denial of your application.

March 2000