Child Care Scholarship -2014 The Child Care Scholarship Fund is an NYU program established to assist eligible fulltime faculty, administrators, and research staff with child care expenses for children under the age of five (5) years. One scholarship grant is available per eligible family per year. Applicants must reapply for a Child Care Scholarship each year. All eligible employees must apply during the annual application period, August 29 through September 15, 2013 for expenses anticipated during Calendar Year 2014. To be considered eligible for a scholarship during Calendar Year 2014: Your total household income for 2012may not have exceeded $130,000. You must be a single parent or your spouse/domestic partner must be employed, disabled, or a full-time student. If your partner/spouse is also employed by NYU as a full-time faculty, administrator, or research staff member, only one individual is eligible to receive a child scholarship or subsidy. Your child(ren) must be under five (5) years of age on December 31, 2013. Your child must be cared for in a licensed family child care home, child care center, nursery school, or in your own home. Your child care expenses must be incurred so that you and, if applicable, your spouse/domestic partner can work. Your child care provider must provide a Tax Id or Social Security number and must report the child care income on their tax return. Your caregiver cannot be your spouse, domestic partner, or dependent. 2014 ONLINE APPLICATION DEADLINE: midnight Sunday, September 15, 2013 QUESTIONS? Contact livesmart@nyu.edu.
Applicant Background Name: University ID# (on reverse side of NYU ID Card): Office Phone: () Please identify your position with NYU: Faculty (102) Administrator (100) Researcher (103) Please check all that apply: You are a single parent You have a spouse or a domestic partner who is Employed Looking for work and receiving unemployment benefits. Please provide date unemployed: Disabled A full-time student. Please indicate school: Your combined household income before taxes for 2012 and 2013 is less than $130,000. You have a child who is younger than five (5) years on December 31, 2013. Your child is enrolled in licensed or legally operating care during your and, if applicable, your spouse/partner s work hours.
To apply for the Child Care Scholarship online click here. Applications will be accepted online until midnight Sunday, September 15, 2013. The application for the Child Care Scholarship is divided into four parts. When you apply online, all four parts of the application must be completed and submitted at the same time. Therefore, we recommend that you fill out the worksheet pages before you submit your application. The form is easy to complete and you will have the opportunity to review each of the four parts, make changes to the information, and print the confirmation sheet before moving on to the next part. The form is not complete until you submit the certification page. You will receive an email confirmation that your application was received. The application requests information about your family size and household income as well as your current or anticipated child care and the cost for child care services. To complete the form you will need to provide information on the following: Part 1. Your household Your name and the name, age, employment status, employer name, and estimated gross income of each household member over the age of 18 years Copies of the first two pages of your 2012 Federal IRS Tax forms, W-2 forms, and a copy of IRS Schedule C, if your spouse/domestic partner is self-employed, scanned and attached to the application submission. Part 2. Your children The names of your children, newborn through 4 years of age as of December 31, 2013, who require care during the 2014 calendar year Their dates of birth The type(s) of child care services you will use for each during 2014 Part 3. Your child care The name and address of each individual or program you expect will provide care for each of your children during the 2014 calendar year Each caregiver's Social Security number or Employer Identification number The anticipated cost for child care services during calendar year 2014 The dates and the number of hours each week you need care Part 4. Your unusual or anticipated expenses The details of significant increases or decreases in your household income and unusual expenses anticipated during the 2014 calendar year. Don't forget: When you apply online, all four forms must be completed and submitted at the same time. Please be sure to utilize the enclosed form as your worksheet and/or have all the necessary documentation when you submit your application.
Employee & Family Information Applicant Name: Work Phone: Email: School/Unit and Department: Work Address: Name of Spouse/Domestic Partner Name of Spouse/Domestic Partner s Employer Home Address (Street, Apt, City, State, Zip) Home Phone: First: ( ) ( ) Last: Including yourself how many adults (18+ years) live in your household? How many children will live in your household during the 2014calendar year? How many children are younger than five (5) years of age on December 31, 2013? What is the total number of household members including yourself? Financial Statement of Household Income Household Income (*includes NYU & non-nyu income) Please include financial information for yourself and all members of your household (your spouse, domestic partner, and other adults) who are 18 years or older regardless of their earning status. First Name Last Name Relationship Age Employed Y/N Self Estimated Gross Income for 2013 Please scan and attach: 1. The completed and signed copies of the first two pages of yours and your spouse or domestic partner s 2012 Federal Income Tax Form 1040 or 1040A and W-2 forms. 2. A copy of 2012 IRS Schedule C if your spouse/domestic partner is self-employed. 3. Copies of yours and your partner s two most recent paycheck stubs.
Instructions and Eligibility Please identify each child under the age of five (5) years who requires child care for calendar year 2014 (1/1/2014-12/31/2014). If you use more than one type of child care per child (for example, in-home care and child care center) please provide information on each. (If you have a shared custody arrangement, include only those child care expenses for which you are responsible.) Please remember: In order to be eligible for a child care scholarship your child must be under five (5) years of age on December 31, 2013 and s/he must be someone you or your registered domestic partner claim as a dependent on your tax return. Eligible child care expenses include: Payments made for services outside your home, such as pre-school tuition (below kindergarten), child care centers, family child care, school holiday and vacation programs, summer recreational day camps, etc. Payments made for services in your home as long as the services are not provided by someone you also claim as a dependent, nor by a child of yours under 19 years of age, whether or not a dependent. Payments made for services that provide care for your child(ren) so that you and your spouse/domestic partner can work.
Child Care Information Applicant Name: Work Phone: Before you apply for a child care scholarship, please carefully read the instructions and eligibility information on the previous pages. We have provided you with worksheet forms for two children. As you complete this worksheet, be sure to copy and prepare a separate page for each additional child. When you apply online the computer will automatically upload the correct number of pages. Information Child #1 First Name Last Name Actual or expected date of birth (mm/dd/yyyy) Is your child s birth certificate filed with the Benefits Office? Yes No Does your child live with you? Yes No Do you claim your child as a dependent on your taxes? Yes No Please check below the type(s) of child care you will use for this child during Calendar Year 2014 Please check all that apply. In-Home Care Child Care Center Relative Care Nursery School Family Child Care
Child Care Provider / Program & Child Care Expense Information Please provide information for child care anticipated for Calendar Year 2014. Complete information on each your child care provider or program who will care for your child and the child care expense on each. There is space for up to two (2) child care providers for each child. How many child care providers do you use for this child? Provider / Program 1 Provider / Program 2 Provider / Program Name: Provider / Program Name: Address (Street, Town, State, Zip Code) where care is Provided: Address (Street, Town, State, Zip Code) where care is Provided: Provider s Social Security or Tax Id Number: Provider s Social Security or Tax Id Number: Fees are paid: Monthly Weekly Fees are paid: Monthly Weekly Cost of child care per month or week: Cost of child care per month or week: # of children this pays for: # of children this pays for: Number of hours care is received for fee period: Number of hours care is received for fee period: Please enter the dates (mm/dd/yyyy) you require this care provider: Period 1 - From: / / Period 2 - / / From: / / / / Please enter the dates (mm/dd/yyyy) you require this care provider: T Period o 1 - : Period 2 - / From: / / / / From: / / / / /
Child Care Information Applicant Name: Work Phone: Before you apply for a child care scholarship please carefully read the instructions and eligibility information on the previous pages. We have provided you with worksheet forms for two children. As you complete this worksheet, be sure to copy and prepare a separate page for each additional child. When you apply online the computer will automatically upload the correct number of pages. Information Child #2 First Name Last Name Actual or expected date of birth (mm/dd/yyyy) Is your child s birth certificate filed with the Benefits Office? Yes No Does your child live with you? Yes No Do you claim your child as a dependent on your taxes? Yes No Please check below the type(s) of child care you will use for this child during Calendar Year 2014. Please check all that apply. In-Home Care Child Care Center Relative Care Nursery School Family Child Care
Child Care Provider / Program & Child Care Expense Information Please provide information for child care anticipated for Calendar Year 2014. Complete information on each your child care provider or program who will care for your child and the child care expense on each. There is space for up to two (2) child care providers for each child. How many child care providers do you use for this child? Provider / Program 1 Provider / Program 2 Provider / Program Name: Provider / Program Name: Address (Street, Town, State, Zip Code) where care is provided: Address (Street, Town, State, Zip Code) where care is provided: Provider s Social Security or Tax Id Number: Provider s Social Security or Tax Id Number: Fees are paid: Monthly Weekly Fees are paid: Monthly Weekly Cost of child care per month or week: Cost of child care per month or week: # of children this pays for: # of children this pays for: Number of hours care is received for fee period: Number of hours care is received for fee period: Please enter the dates (mm/dd/yyyy) you require this care provider: Period 1 - From: / / Please enter the dates (mm/dd/yyyy) you require this care provider: Period 1 - From: / / / / / / Period 2 - From: / / Period 2 - From: / / / / / /
Miscellaneous Information Applicant Name: Work Phone: Please explain any significant decreases or increases between your total expected income for 2013 and your 2012 household income. Please describe (providing total annual cost) any unusual significant expenses anticipated during 2014. (Examples: medical costs for which you are not reimbursed, costs to care for a dependent adult.) Please provide any other information that will help us better understand your family situation during 2014.
Child Care Scholarship 2013 Certification Applicant Name: Work Phone: IMPORTANT: Please be sure to complete this page when applying on-line. If you do not submit this final page your application will not be complete and will not be submitted for consideration. When this form is submitted you will receive an email confirming that your application has been received. By submitting this application, I certify that the information provided is complete and accurate. I understand that I may be asked for and must provide copies of documentation to support any of the information provided as part of this application. I understand that I must notify the Benefits Office of any family status changes (i.e. dissolution of marriage or domestic partnership) or other changes which could affect my child custody responsibilities or eligibility to participate in or receive reimbursements from a Dependent Care Flexible Spending Account during the plan year in which I receive a Child Care Scholarship. I understand that incomplete or inaccurate information may adversely affect my eligibility under the Child Care Scholarship Program and could result in my being required to repay to New York University any funds awarded and/or my being subject to disciplinary action up to and including termination. I understand that only one scholarship grant is available per eligible family per year. Submitted by: Date: YOU WILL RECEIVE AN EMAIL CONFIRMING THAT YOUR APPLICATION HAS BEEN PROCESSED. QUESTIONS? CONTACT livesmart@nyu.edu