Form DD Form 2652 DD Form 2652 Application for Department of Defense Child Care Fees

CUI (when filled in)
OMB No. 0704-0515
OMB approval expires
YYYYMMDD

APPLICATION FOR DEPARTMENT OF DEFENSE CHILD CARE FEES
(Read Instructions on back before completing form.)

The public reporting burden for this collection of information is estimated to average 5 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 aspect of
this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; 10 U.S.C. 8013, Secretary of the Air Force;
DoD Instruction 6060.02, Child Development Programs; Army Regulation 608-10, Child Development Services; OPNAV Instruction 1700.9E series, Child and Youth Programs; Marine
Corps Order P1710.30E, Children, Youth, and Teen Program (CYTP); Air Force Instruction 34-144, Child and Youth Programs.
PRINCIPAL PURPOSE(S): To collect total family income to determine child care fees.
ROUTINE USE(S): Department of the Army records may be disclosed to civilian health and welfare departments/agencies in emergencies. Department of the Navy records may be
disclosed to local, state and Federal officials involved in child care services, if required, in the performance of their official duties relating to child abuse reporting and investigations.
Department of the Air Force records may be disclosed to civilian health and welfare departments/agencies in emergency situations.
Additional Routine Uses can be found in the SORNS: Department of the Army: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570083/a0608acfsc/; Department of the Navy: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570428/nm01754-3/; Department of the Air Force: https://
dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569755/f034-af-sva-c/;
DISCLOSURE: Required. Failure to provide the required information will delay the processing and approval of child care services.

SECTION I - DEPENDENT CHILDREN
1. NAME OF EACH CHILD (Last, First, Middle Initial)

2. DATE OF BIRTH
(YYYYMMDD)

3. AGE

4. CARE REQUESTED (OR ENROLLED)

a.

DRAFT

b.
c.
d.
e.

SECTION II - ANNUAL FAMILY INCOME
5. SPONSOR
b. YEARS OF MILITARY/CIVIL SERVICE

a. NAME (Last, First, Middle Initial)

c. INCOME
(1) Income Data (2) Basic Allowance for Housing
(BAH)

(3) Basic Subsistence Allowance

(4) Other Earned Income (5) Total Income - Sponsor (To
be completed by Program Staff)

6. SPOUSE OR OTHER ADULT LIVING IN THE HOME
a. NAME (Last, First, Middle Initial)

b. INCOME

7. OTHER INCOME EARNED

8. TOTAL INCOME (Include income from Blocks 5, 6, and
7. To be completed by Program Staff.)

SECTION III - CERTIFICATION OF SPONSOR/DESIGNEE
(Required for all categories. Please read the following statement carefully before signing.)
I certify that all of the above information is true and correct and that all family income of the spouse and sponsor is reported. I understand that this information is being given in order to
determine child care fees to be paid and that Federal funds are used to subsidize the cost of child care. I also understand that the installation commander may verify the information on
the application; and that deliberate misrepresentation of this information may subject me to prosecution under applicable State and Federal laws. See 18 U.S.C. Section 1001.

9. SIGNATURE OF SPONSOR

10. SIGNATURE OF SPOUSE

11. DATE SIGNED (YYYYMMDD)

SECTION IV - FOR CHILD DEVELOPMENT PROGRAM USE ONLY
12. PRIORITY SYSTEM
ELIGIBILITY

13. CATEGORY OF APPROVAL 14. AUTHORIZED FEES

DD FORM 2652, OCT 2020
PREVIOUS EDITION IS OBSOLETE.

15. DATE OF APPROVAL 16. NAME OF CHILD DEVELOPMENT
PROGRAM OFFICIAL
(YYYYMMDD)

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Controlled by: OUSD(P&R)
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Distribution/Dissemination Control: FEDCON
POC: [email protected]

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INSTRUCTIONS

Per Department of Defense Instruction 6060.02, Child Development Programs, this form is utilized to determine fees for DoD Child Care Programs.
To determine child care fees for your child(ren), or and child(ren) you legally claim as dependents, this from must be completed, signed and returned to the facility
for which your child is enrolling.
Fees are determined based on your Total Family Income (TFI) as defined below. TFI documentation is required for child care rate determination.
Total Family Income (TFI) - For the purpose of determining child care fees in DoD Child Development Programs, total family income is defined as all earned
income including wages, salaries, tips, special duty pay (flight pay, active duty demo pay, sea pay) and active duty save pay, long-term disability benefits,
voluntary salary deferrals, retirement or other pension income including SSI paid to the spouse and VA benefits paid to the surviving spouse before deductions
for taxes. TFI calculations must also include quarters subsistence and other allowances appropriate for the rank and status of military or civilian personnel
whether received in cash or in kind.
DO NOT INCLUDE alimony, and child support received by the custodial parent, SSI received on behalf of the dependent child, reimbursements for educational
expenses or health and wellness benefits, cost of living (COLA) received in high cost areas, temporary duty allowances, or reenlistment bonuses.
For households in which unmarried couples or pairs are living as a family, the income for both adults should be used to determine Total Family Income (TFI).
Sections I, II, and III are to be completed by the sponsor or their designee.
Section I.
1. Provide the last name, first name and middle initial for each child who is receiving care in a DoD child care program.
2. Provide the date of birth for each child who is receiving care in a DoD child care program.

DRAFT

3. Provide the age of each child on the date of application who is receiving care in a DoD child care program.
4. Provide the type of care being request or in which each child is currently enrolled.
Section II.

When completing Section II, include all military and civilian income for both the sponsor and spouse or other adult living in the home.
5.a. Provide the sponsor’s last name, first name and middle initial.
5.b. Provide the total years of military/civilian service as applicable.
5.c.(1) Provide your most recent income data and indicate if income is received weekly, biweekly, monthly or twice per month.
5.c.(2) Provide the current year BAH RT/C. For dual military living in government quarters include BAH RC/T of the senior member only; in locations where
military members receive less than the BAH RC/T allowance, use the local BAH rate; for Defense civilian OCONUS include either the housing allowance or the
value of the in-kind housing.
5.c.(3). Provide the basic subsistence allowance or in-kind equivalent.
5.c.(4) Provide any other earned income.
5.c.(5) To be completed by program staff.
6.a. Provide the last name, first name and middle initial of the spouse or other adult living in the home, who contributes to the welfare
of the child.
6.b. Provide the income of the spouse or other adult living in the home, who contributes to the welfare of the child.
7. Provide any additional income.
8. To be completed by program staff.
Section III.
9. Provide the sponsor's signature.
10. Provide the spouse's or other resident adult's signature.
11. Provide the date of signatures.

DD FORM 2652, OCT 2020
PREVIOUS EDITION IS OBSOLETE.

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