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U.S.
Office of Personnel Management
Guide
for Implementing |
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U.S.
Office of Personnel Management
Guide
for Implementing |
Appendix F
Child Care Provider Information Form OPM Form 1644
This form is optional. Agencies may develop their own form, if they wish.If agencies develop their own form, it will require OMB clearance.
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Form Approved OMB No. 3206-0240 |
Child Care Provider Information For
Child Care Tuition Assistance Program for Federal Employees
Department (insert agency name)
This information is requested by the Department (insert agency name) administrator for their Child Care Tuition Assistance Program to verify licensure and/or regulation status. Once you are notified by a Federal employee that they have submitted an application for child care tuition assistance from their Federal agency, please complete this form and mail it to:
(Program Administrator Name and Address)
1. Child Care Provider
a. Name: __________________________________________________________________
b. Address: ________________________________________________________________
c. Check one: Family Child Care _____ Center-based Child Care _____
2. Organization(s) that licenses or regulates your child care program and the most recent date of your license or regulatory approval:
a. Name ______________________________________________ Date: _______________
b. Name______________________________________________ Date: _______________
*Attach your most recent license or other notification of approval to operate.
3. Children of Federal employees who have applied for tuition assistance:
Name ________________________________________ Weekly tuition: _______________
Parent Names ________________________________
Weekly subsidy amount from State or local governments: $________________________
Name_________________________________________ Weekly tuition: _______________
Parent Names _________________________________
Weekly subsidy amount from State or local governments: $________________________
To list additional children, use attached sheet.
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OPM Form 1644 April 2000 |
I certify that the above statement is correct as I know it. I understand it is a Federal crime under USC, Title 18, section 1001, to make a false statement on this form. If I make a false statement, I may be subject to criminal prosecution and punishment including a fine, imprisonment, or both.
Signature of individual completing this form: ______________________________________
Name of individual completing this form: __________________________________________
Title: ______________________________________ Telephone: ________________________
Federal ID or SSN#: _________________________ Fax:______________________________
Date: _______________________
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 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 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.
Public Burden Statement:
We think this form takes an average of 10 minutes to complete including the time for getting the needed data and reviewing both the instructions and completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Reports and Forms Manager, Paperwork Reduction (3206-0240), Washington, DC 20415-7900. The OMB Number, 3206-0240, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
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OPM Form 1644 April 2000 |
Children of Federal employees who have applied for tuition assistance:
Name ________________________________________ Weekly tuition: _______________
Parent Names ________________________________
Weekly subsidy amount from State or local governments: $________________________
Name_________________________________________ Weekly tuition: _______________
Parent Names _________________________________
Weekly subsidy amount from State or local governments: $________________________
Name ________________________________________ Weekly tuition: _______________
Parent Names ________________________________
Weekly subsidy amount from State or local governments: $________________________
Name_________________________________________ Weekly tuition: _______________
Parent Names _________________________________
Weekly subsidy amount from State or local governments: $________________________
Name ________________________________________ Weekly tuition: _______________
Parent Names ________________________________
Weekly subsidy amount from State or local governments: $________________________
Name_________________________________________ Weekly tuition: _______________
Parent Names _________________________________
Weekly subsidy amount from State or local governments: $________________________
Name ________________________________________ Weekly tuition: _______________
Parent Names ________________________________
Weekly subsidy amount from State or local governments: $________________________
This page may be photocopied if additional space is needed.
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OPM Form 1644 April 2000 |
Page updated 20 April 2000