Form OPM 1644 OPM 1644 Child Care Provider Information for the Child CareTuitio

Form Approved:
OMB No. 3206-0240

Child Care Provider Information for the Child Care Tuition Assistance Program
for Federal Employees
This information is required by law to verify that you are a licensed and/or regulated provider.
Child Care Provider: Complete this form and return it to the parent along with a copy of your latest license and/or regulatory document.
Employee: Return the completed form and copy of the license and/or regulatory document to the agency Child Care Subsidy Coordinator.

A. Agency Information
1. Full agency name

2. Agency mailing address

3. Program Administrator's name

5. Program Administrator's email address

4. Program Administrator's telephone number

B. Child Care Provider Information
1. Child Care Provider's full name
2. Child Care Provider's address (including street number, city, state and ZIP code)

3. Check the box below to show the type of
care you provide
Family Child Care
Center-based Child Care

4. Give the organization name(s) that license or
regulate your child care program and the expiration
date of your license or regulatory approval

Organization Name

License or Approval Expiration Date

Attach your most recent license or other
notification of approval to operate
(for example: approval by the County Board of
Education)
5. Please furnish the information below for each Federal employee who applied for tuition assistance at your facility:
Parent's name

Office of Personnel Management

Child's name

Weekly Tuition

Form authorized for local reproduction

Weekly Subsidy Amount from
State or Local government

OPM 1644
Revised March 2008
Previous editions not usable

5. Continued - Please furnish the information below for each Federal employee who applied for tuition assistance at your facility:
Parent's name

Weekly Tuition

Child's name

Weekly Subsidy Amount from
State or Local government

6. I certify that the above information 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.
7a. Signature of individual completing form
7b. Date signed

8. Typed or printed name of individual completing form
10. Federal Tax ID or Social Security Number

9. Title

11. Telephone number

12. FAX number

Privacy Act Statement:
Public Law 106-554, Section 633 (September 29, 2000) 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 1644 (Back)
Revised March 2008