Form 2900-0717 VA Form 0730b

OMB Approved No. 2900-0717
Respondent Burden: 20 Minutes
Expiration Date: XX/XX/20XX

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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it a currently valid OMB control
number. The OMB control number for this project is 2900-0717, and it expires XX/XX/20XX. Public reporting for this collection of information is estimated to average 20 minutes per
respondent, per year, 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 this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Officer at
VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0717 in any correspondence. Do not send your VA Form 0730b to this email address.
INSTRUCTIONS: Employees approved to participate in the VA Child Care Subsidy Program must use this form to request monthly child care subsidy benefit payments. An invoice from
the child care provider must be prepared indicating the total cost of daycare and uploaded into the Child Care Record Management System (CCRMS) each month benefits are requested. The
child care provider's invoice should include the name and address of the provider or company, the provider's Federal tax identification number, a description of services and the total cost of
monthly services.

Request for benefits should be uploaded into CCRMS by the 15th of each month unless the date falls on a weekend and/or holiday then the submission deadline will move to the following
business day.
NOTE: As a participant in the VA Child Care Subsidy Program, you are eligible to receive a subsidy to be applied towards your child care cost. Your monthly child care subsidy will be
forwarded to your child care provider on your behalf. However, you are responsible for the payment of your total child care cost and must pay the full amount on all invoices issued to you by
your child care provider, if no VA CCSP benefit credit is available on your account. Any arrangement you make with your provider regarding how your child care subsidy benefits are credited
and/or any payment arrangements on your account is between you and your child care provider.

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

2. FEDERAL AGENCY OF PARENT

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

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

BEFORE SCHOOL CARE

AFTER SCHOOL CARE

BEFORE AND AFTER 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

D. SOURCE OF SUBSIDY

E. AMOUNT OF
SUBSIDY

F. TOTAL WEEKLY
FEE FOR CHILD

"YES," complete
D and E.)
YES
NO
YES
NO
YES
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

VA FORM
SEP 2024

0730b

2. TITLE OF PROVIDER REPRESENTATIVE

3. SIGNATURE OF PROVIDER (Sign in ink)

SUPERSEDES VA FORM 0730b, JUL 2007-2021,
WHICH WILL NOT BE USED.

4. DATE SIGNED

(MM/DD/YYYY)