Cf 2900 Form – Fill Out and Use This PDF

Affordable Child Care Benefit Application

See 'About Affordable Child Care Benefit' and the 'Forms and Documents Checklist' at the end of this form for more information or visit gov.bc.ca/affordablechildcarebenefit

Changes to any of the information you provide must be reported to the Child Care Service Centre at 1-888-338-6622.

Section 1 - Family Members

A 'Family' is the applicant, spouse or partner, and dependent children living in the home.

Applicant

Gender

Date of Birth (yyyy-mmm-dd)

Primary Phone Number

Primary Phone Number Type

Male

Female

Home

Cell

Work

Secondary Phone Number

Secondary Phone Number Type

Social Insurance Number (SIN)

Home

Cell

Work

Status in Canada:

Canadian Citizen

Permanent Resident of Canada

Convention Refugee/Person in Need of Protection

Home Address

Mailing Address

Spouse

A person who resides with the parent in a married, or marriage-like relationship for at least 3 months who shares income and/or expenses and who has a social and familial relationship.

	Spouse's Last Name				First Name	Middle Name
	Gender				Date of Birth (yyyy-mmm-dd)	Social Insurance Number
		Male		Female

Dependent Children

The number of dependants living in your home affects your eligibility. List all dependent children under the age of 19 living in the home even if child care is not required for the child.

CF2900_(19/04)

Security Classification: MEDIUM SENSITIVITY

Page 1 of 7

Last Name

First Name

Middle Name

Gender

Date of Birth (yyyy-mmm-dd)

This person (check all that apply):

Male

Female

requires

is a child with designated

is a child living with you

childcare.

special needs.

via a ministry placement.

Last Name

First Name

Middle Name

Gender

Date of Birth (yyyy-mmm-dd)

This person (check all that apply):

Male

Female

requires

is a child with designated

is a child living with you

childcare.

special needs.

via a ministry placement.

Last Name

First Name

Middle Name

If yes, please enter the details of the custody arrangement. Include the name of the child(ren), days and times they reside with you (use section 4 on page 3 if you require more space).

Section 2 - Reason for Needing Child Care

To be eligible, you and your spouse need a reason for child care. Select your reason below. If eligible, the Affordable Child Care Benefit may be provided for the time doing this activity. You are responsible for any extra care if you choose to have care during other days or times. If the reason is medical, the amount of Child Care supported will be listed by your doctor on the Medical Condition Form. If you are referred by a Social Worker, the amount of time supported will be listed by the Social Worker on your Referral for Affordable Child Care Benefit Form. If your child attends a licensed preschool, only the time spent at the licensed preschool will be supported unless there is an additional reason for care.

Applicant

Do you have (check all that apply):

a medical condition?

a child in a licensed preschool?

Are you currently (check all that apply):

employed

self-employed

attending an employment program

attending school

looking for work

Days per week you do this activity on days when you also require child care (check all that apply)

Mon

Tues

Wed

Thu

Fri

Sat

Sun

If you have a set schedule, you usually:

If your schedule varies, you average:

Start at:

AM

PM

and End at:

AM

PM

hours per day:

days per week:

Additional Information (or attach a schedule)

Spouse

Does your spouse have (check all that apply):

a medical condition?

a child in a licensed preschool?

Is your spouse currently (check all that apply):

employed

self-employed

attending an employment program

attending school

looking for work

CF2900_(19/04)

Security Classification: MEDIUM SENSITIVITY

Page 2 of 7

Days per week you do this activity on days when you also require child care (check all that apply)

Mon

Tues

Wed

Thu

Fri

Sat

Sun

If your spouse has a set schedule, they usually:

If your spouse's schedule varies, they average:

Start at:

AM

PM and End at:

AM

PM

hours per day:

days per week:

Additional Information (or attach a schedule)

Section 3 - Income

Eligibility for the Affordable Child Care Benefit is partially based on income. You will need to consent to having your income information disclosed by the Canada Revenue Agency (CRA). This consent is required even if you have not filed your tax return within the last two years. The Child Care Service

Centre will use your most recent tax information, within the last two years, from CRA to assess your eligibility. Complete the Consent to Collect CRA Records (CF2930) form for you and your spouse (if applicable) located on the last page of this application.

If you or your spouse (if applicable) have not filed a tax return with CRA within the last two years, or if you are applying for an Income Review, you must also complete the Income Declaration (CF2933) form.

Section 4 - Comments

Please provide any additional information you would like us to know about.

Section 5 - Declaration and Consent

Applicant:

•I confirm the information I have supplied is true and complete.

•I understand I am required to promptly supply information to the Child Care Services Centre if there is a change in my or my family’s circumstances affecting my eligibility for the benefit

•I understand it is an offence under the Child Care Subsidy Act to supply false or misleading information.

•I understand a benefit may be paid from the first day of the month in which the application is completed, or the date child care begins, whichever is later. I am responsible for child care fees prior to this date.

•I consent to the verification of information provided regarding this application, or any subsequently provided information.

•I authorize third parties to disclose personal information about me to verify information I have supplied and that the minister needs for the purposes of determining or auditing my eligibility for the benefit as set out in section 5 of the Child Care Subsidy Act.

•I consent to the indirect collection by the Child Care Service Centre of verifying information disclosed to it by third parties for the purpose of determining or auditing my eligibility for the Affordable Child Care Benefit.

Consent to share information

As the applicant, do you consent to the disclosure of information to your spouse, as identified on this form, relating to this application or your eligibility for Affordable Child Care Benefit by the Child Care Service Centre?

This application is not valid until it has been signed and dated

CF2900_(19/04)

Security Classification: MEDIUM SENSITIVITY

Page 3 of 7

Spouse or Partner

•I confirm the information I have supplied is true and complete. I understand it is an offence under the Child Care Subsidy Act to supply false or misleading information.

•I consent to the indirect collection by the Child Care Service Centre of verifying information disclosed to it by third parties for the purpose of determining or auditing my eligibility for the Affordable Child Care Benefit. I authorize third parties to disclose personal information about me to verify information I have supplied and that the minister needs for the purposes of determining or auditing eligibility for the benefit as set out in section 5 of the Child Care Subsidy Act.

Submit your Completed Application and Supporting Documents

Fax or mail your completed application and supporting document copies to the Child Care Service Centre. Keep a copy for your records.

If you are faxing your application, please print your name on the top of every page.

Toll Free Fax:

1-877-544-0699

Mailing Address: Child Care Service Centre

PO Box 9953 Stn Prov Govt

Victoria BC V8W 9R3

For more information, call the Child Care Service Centre toll free at 1-888-338-6622.

CF2900_(19/04)

Security Classification: MEDIUM SENSITIVITY

Page 4 of 7

About the Affordable Child Care Benefit

For Information Only - Do not submit this page with your application.

Forms and Documents Checklist

Which Supporting Documents are Required with my Application?

Forms are available at gov.bc.ca/affordablechildcarebenefit

Child Care Arrangement Form (CF2798)

You and your Child Care Provider must complete this form. A separate form is required for each child care provider.

Identification for all Family Members

A copy of government-issued identification (birth certificate, Canadian Citizenship Card, passport, driver's license, provincial identification, BC Services Card, Certificate of Indian Status Card).

Citizenship Status in Canada for Applicant

A copy of any formal document issued by Citizenship and Immigration Canada that confirms your status in Canada.

Special Needs Form (CF2951) for children designated as special needs

Proof of Reason for Needing Child Care

Reason for needing child care	Documents required to support your proof of reason
Education	Student loan notice of assessment or school registration and class
	schedule
Looking for work	Keep track of looking for work activities (CF2910)
Employment Program or SPEI	Copies of registration in employment program or SPEI Action Plan
Medical Condition	Medical Condition Form (CF2914)
Social Worker Referral	Referral to Affordable Child Care Benefit (CF2044) from Social Worker
Child attending preschool	Child Care Arrangement Form (CF2798)

Proof of Family Income

The attached Consent to Collect CRA Records (CF2930) form is required for you and your spouse (if applicable) even if you have not filed your tax return within the last two years.

The Income Declaration (CF2933) form is also required to declare your or your spouse’s income if either of you have not filed a tax return with CRA within the last two years, or if you are applying/have applied for an Income Review.

For Information Only - Do not submit this page

Send Copies of your Documents. Not the originals.

Affordable Child Care Benefit

Consent to Collect CRA Records

The personal information collected on this form is collected under the authority of the Freedom of Information and Protection of Privacy Act for the purpose of administering the Child Care Subsidy Act. The Freedom of Information and Protection of Privacy Act protects the personal information collected from unauthorized use and disclosure. If you have any questions about the collection, use or disclosure of this information, please call the Child Care Service Centre at 1-888-338-6622 or inquire in writing to the address at the end of this form.

This form is required for the applicant and spouse (if applicable) to consent to collect CRA income records for the purpose of assessing eligibility for the Affordable Child Care Benefit.

I hereby consent to the disclosure of information from my income tax records, and other taxpayer information, by the Canada Revenue Agency to an official of the Ministry of Children and Family Development. The information disclosed will be relevant to, and used solely for the purpose of, determining and verifying my eligibility for child care subsidy and for determining the amount of my benefit under the Affordable Child Care Benefit under the Child Care Subsidy Act. The information disclosed by the Canada Revenue Agency to the Ministry of Children and Family Development will be protected from unauthorized use or disclosure and will only be used and disclosed in accordance with the Freedom of Information and Protection of Privacy Act.

I also permit the Ministry of Children and Family Development to collect information from my income tax records, and other income tax information, from the Canada Revenue Agency, instead of directly from me.

I also consent to the disclosure of my first and last name, birth date and Social Insurance Number by the Ministry of

Children and Family Development to the Canada Revenue Agency. This information will be used by the Canada Revenue Agency to identify the taxpayer information to be disclosed to the Ministry of Children and Family Development.

I further permit the Ministry of Children and Family Development to display my income tax information from the Canada Revenue Agency on my assessment letter, and if registered for My Family Services, on the electronic online portal, for the purpose of describing how financial eligibility was calculated.

This consent permits the Canada Revenue Agency to disclose information from my tax records and other taxpayer information from the two most recent taxation years prior to the year of signature of this consent, the year of the

signature, and each subsequent consecutive taxation year for which benefit is requested by me or on my behalf. It may be revoked at any time by sending a notice to the Director of the Child Care Service Centre. The statement of consent

and any subsequent revocation can be provided in paper or electronic format.

Once completed, please fax or mail to the Child Care Service Centre

Toll Free Fax 1-877-544-0699	Mailing Address
Toll Free Phone 1-888-338-6622	Child Care Service Centre
	PO Box 9953 Stn Prov Govt
	Victoria BC V8W 9R3

CF2930_(19/04)

Security Classification: MEDIUM SENSITIVITY

Page 7 of 7