Naccrra Application – Fill Out and Use This PDF

1515 N. Courthouse Rd, 11th flr Arlington, VA 22201 Phone: 1-800-793-0324 x341 Fax: 703-341-4103 msp@naccrra.org

Military Fee Assistance Programs

PARENT ELIGIBILITY APPLICATION

You may also apply online at www.fap.americasteamforchildcare.org

Name of Parent/Military Sponsor: _____________________________________________________

ON THIS PAGE, COMPLETE ONLY ONE OF THE 5 BLOCKS BELOW

Operation Military Child Care (OMCC)

Check one:

Activated/Deployed National Guard or Reserve Service Member

Deployed Active Duty Soldier, Sailor, Airmen, or Marine unable to access child care on a military installation

OR

Military Child Care in your Neighborhood (MCCYN)

Active Duty Soldier, Sailor, Airmen, Marine, AGR Guard and Reserve unable to access child care on a military installation

Military civilian unable to access child care on a military installation

Active Duty (check one):  Army ASPYN (Army School age Program in Your Neighborhood)

Army  Army National Guard  Army Reserve  Navy  Marine Corps

 Air Force  Air Force Reserve  Air National Guard  Military Civilian

OR

Army Child Care in Your Neighborhood (ACCYN)

 Fort Leonard Wood Fort Campbell Fort Riley Fort Sam Houston Fort Lewis USAG Miami Fort Hood, TX Fort Myer, VA

OR

Army School Age Program in Your Neighborhood (ASPYN)

Parent/Military Sponsor Name: __________________________________________________

Type of Application (check one):

Initial Application

Change of information, eligibility criteria, status, etc.

SECTION A. HOUSEHOLD INFORMATION

1.SERVICE MEMBER (SPONSOR) CONTACT INFORMATION: REQUIRED

Is this the address where child resides? Yes No

Email Address (used for all communication): ___________________________________________________________

Installation assigned to: ________________________________________________________

Parent/Military Sponsor Name: __________________________________________________

Email Address: ________________________________________________________

PARENT/LEGAL GUARDIAN CERTIFICATION: (Please read carefully; check all boxes, sign and date in

designated area)

In addition to this form I have submitted:

(Fax, mail, or email these documents to NACCRRA.)

•Service Member’s military orders (activated/deployed only)

•Leave and Earning Statements (LES) for the service member

•Spouse’s most recent pay stub (one month) or proof of enrollment in school

•Child(ren)’s birth certificate or self certification statement

ICERTIFY THAT:

I am the parent or legal guardian of the child(ren) listed and I may be required to submit proof of such, in order to receive reduced fee child care.

All information submitted in this application is true and correct.

All family income of the spouse and service member sponsor is reported.

IUNDERSTAND THAT:

This information is being given in order to determine child care fees to be paid.

This information is being given in connection with military funds used to reduce the cost of child care.

Military and NACCRRA officials may verify any information on this application at any time they deem necessary.

Deliberate misrepresentation of this information may result in prosecution under applicable State and Federal laws. See 18 U.S.C/ Section 1001.

Any misrepresentation or falsification of information that is in any way related to reduced child care fee, may result in reclaiming any money paid for child care and may be punishable under criminal law.

Eligibility for the reduced child care fee is determined based on Military eligibility requirements.

NACCRRA MILITARY PROGRAMS may only pay up to the state’s local market rate for child care fees.

I must select a qualified child care provider/program that meets the qualifications necessary to participate in the NACCRRA MILITARY PROGRAMS. The NACCRRA MILITARY PROGRAMS will not reimburse any child care provider/program who is not qualified.

I must give NACCRRA MILITARY PROGRAMS a minimum of two (2) weeks notice when changing child care

providers/programs by submitting a CHANGE OF PROVIDER/PROGRAM FORM and a new PROVIDER/PROGRAM INFORMATION AND

REGISTRATION FORM.

I may use more than one provider/program; however, NACCRRA MILITARY PROGRAMS will not reimburse more than one provider/program for the same period of time, for the same child.

If I use a back-up child care provider/program, NACCRRA MILITARY PROGRAMS must reimburse the primary child care provider/program first.

NACCRRA MILITARY PROGRAMS will only make payments directly to the child care provider/program, and not to me. I understand that I must disclose any income including: Long-term disability benefits Voluntary salary deferrals Retirement or other pension income Other Federal and State benefits, etc. Quarters subsistence and other allowances appropriate for the rank and status of military whether received in cash or in kind Anything else of value, even if not taxable,

that was received for providing services

I understand that I may not receive fee assistance for child care both from the Military Branch of Service and NACCRRA at the same time.

If I am an Army family, I understand that I am only eligible to receive 1 Army subsidy per child and may not receive subsidies from GSA and NACCRRA simultaneously.

PARENT/LEGAL GUARDIAN RESPONSIBILITIES AND CERTIFICATION

I [parent or legal guardian] understand/agree (Please check all boxes):

That reduced fee child care for which I am eligible is based on my income, family size, age of child(ren), the provider/program’s location, and the type of child care I select; if there are any changes to my situation, I must make NACCRRA MILITARY PROGRAMS aware of those changes.

To authorize attendance records on a timely basis, to ensure the provider/program may receive timely reimbursement.

To submit proof of my continued eligibility for this program when requested.

To notify NACCRRA MILITARY PROGRAMS at least fifteen (15) calendar days before ending child care services. In cases of emergency please notify NACCRRA MILITARY PROGRAMS immediately (1-800-793-0324).

That the provider/program indicated on this form must meet all state requirements to provide child care services, and that NACCRRA MILITARY PROGRAMS is under no obligation to begin reimbursements before the provider/program has been determined qualified.

I have read all of the above and understand its content. I also understand that non-compliance with any of the

above may result in termination of my reduced child care fee and of my participation in the NACCRRA MILITARY PROGRAMS and I may be required to re-pay any money paid on my behalf