0730b Child Care Provider Information (For the Child Care Subs

OMB Number:
Respondent Burden: 10 minutes

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 (005R1B), 810
Vermont Avenue, NW, Washington, DC 20420. DO NOT send requests for benefits to this address.
INSTRUCTION: This information is required by law for the agency administrator of the Child Care Subsidy Program to verify licensure and/or regulation status. Once
you are notified by a VA employee that they submitted an application for child care subsidy from the Department of Veterans Affairs, please complete this form and
return it to the parent. Please attach a copy of your latest license and/or regulatory document and schedule of fees.
PART I - PARENT INFORMATION
2. FEDERAL AGENCY OF PARENT

1. NAME OF PARENT/LEGAL GUARDIAN WITH CHILD
IN THE PROVIDER'S CARE

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

AFTER SCHOOL CARE

BEFORE AND AFTER SCHOOL CARE

2. CHILD CARE SERVICES (Check only one)
FULL-TIME CARE

BEFORE 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

E. AMOUNT OF
SUBSIDY

D. SOURCE OF SUBSIDY

F. TOTAL WEEKLY
FEE FOR CHILD

NO

$

$

$

$

$

$

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

0730b

Supersedes VA Form 0730b, NOV 2000,
which will not be used.

VA FORM
JUL 2007

3. SIGNATURE OF PROVIDER

4. DATE SIGNED
(MM/DD/YYYY)

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