GSA Subsidy Administration Section U.S. Army Family Enrollment Provider Cost Verification Form

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Cori Hines
10 years ago
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1 U.S. Army Family Enrollment Falls Church 2242 City: State: VA Zip Code: Remit to Address: City: State: Zip Code: Printed Name of Qualifying Sponsor: Last First MI Child's Enrollment (start date of care): of Birth (DOB) Type of Care (check all that apply): FT PT Before School Only After School Only Before and After School Summer/Holiday Full Rate (school aged): Daily Rate = Respite Care $ _ (note: $15 maximum may be paid on behalf of each child per provider, per year) Are there any future rate or attendance changes expected within next six (6) months? GSA Subsidy Administration Program as a qualifying child care provider. *Child care rates & fees must be submitted to the annually. Only one rate Tel: (866) Fax: (816) [email protected] ARMY 215-1

Care $ _ (note: $15 maximum may be paid on behalf of each child per provider, per year) Are there any future rate or attendance changes expected within next six (6) months?

2 U.S. Coast Guard Family Enrollment City: Falls Church State: VA Zip Code: 2242 Remit to Address: City: State: Zip Code: Printed Name of Qualifying Member: Last First MI Child's Enrollment (start date of care): of Birth (DOB) Summer/Holiday Full Rate (school aged): Daily Rate = (note: $2 maximum may be paid on behalf of each child per provider, per year) Are there any future rate or attendance changes expected within next six (6) months? *Child care rates & fees must be submitted to the annually. Only one rate Tel: (866) Fax: (816) [email protected] USCG 215-1

maximum may be paid on behalf of each child per provider, per year) Are there any future rate or attendance changes expected within next six (6)

3 General Services Administration (GSA) Family Enrollment City: Falls Church State: VA Zip Code: 2242 Remit to Address: City: State: Zip Code: Child's Enrollment (start date of care): of Birth (DOB) Summer/Holiday Full Rate (school aged): Daily Rate = Are there any future rate or attendance changes expected within next six (6) months? *Child care rates & fees must be submitted to the annually. Only one rate Tel: (866) Fax: (816) [email protected] GSA 215-1

Daily Rate = Are there any future rate or attendance changes expected within next six (6) months?

4 U.S. Customs and Border Protection (CBP) Family Enrollment City: Falls Church State: VA Zip Code: 2242 Remit to Address: City: State: Zip Code: Child's Enrollment (start date of care): of Birth (DOB) Summer/Holiday Full Rate (school aged): Daily Rate = Are there any future rate or attendance changes expected within next six (6) months? *Child care rates & fees must be submitted to the annually. Only one rate Tel: (866) Fax: (816) [email protected] CBP 215-1

5 National Park Service (NPS) Family Enrollment City: Falls Church State: VA Zip Code: 2242 Remit to Address: City: State: Zip Code: Child's Enrollment (start date of care): of Birth (DOB) Summer/Holiday Full Rate (school aged): Daily Rate = Are there any future rate or attendance changes expected within next six (6) months? *Child care rates & fees must be submitted to the annually. Only one rate 23 Main Stret - 2SE, Kansas City, MO 6418 Tel: (866) Fax: (816) [email protected] NPS 215-1

any future rate or attendance changes expected within next six (6) months?

U.S. Coast Guard Child Care Subsidy Program Benefit Information

U.S. Coast Guard Child Care Subsidy Program Benefit Information The U.S. Coast Guard Child Care Subsidy Benefit program was created to assist U.S. Coast Guard Members who use any federal child care center,