For Office Use Only (DO NOT ENTER SSN): Sponsor ID Number … · 2019-11-21 · signature from the Sponsor and the Child Care Provider. Claim forms submitted after 60 days following

CNICCYP 1700/90 (Rev. 11.20.2019) Page 1 of 2

Navy Child and Youth Programs (CYP) Fee Assistance Program U.S. Coast Guard (USCG) Child Care Subsidy Program (CCSP)

Sponsor/Family Application

For Office Use Only (DO NOT ENTER SSN): Sponsor ID Number Type of application: New Renewal Add a Child

Update Information PCS Reactivation Section I - Sponsor Information

Sponsor Name (Last, First, Middle) Permanent Duty Station Zip Code

Sponsor Rank/Rate Status

Home Address (include street, city, state, and zip code)

Home Phone (include area code) Cell Phone (include area code) Email Address

ETS/Rotation Date Marital Status

Section II - Spouse/Partner Information Spouse/Partner Name (Last, First, Middle)

Address (if different from sponsor)

Grade/Rank (if Federal Employee) Spouse/Partner Place of Employment or School

Spouse/Partner Work Phone Spouse/Partner Cell Phone Spouse/Partner Email Address

Section III - Spouse/Partner Statement of Qualification The USCG requires that the Spouse/Partner of the qualifying USCG Member be employed a minimum of 20 hours per week, enrolled in school a minimum of 6 credit hours per semester, self-employed, or seeking employment in order to qualify for CCSP benefits.

I certify that (spouse or partner’s full name) is a (select multiple if necessary): Full-time Working Spouse/Partner (attach 4 weeks of earning statements)

Part-time Working Spouse/Partner (minimum average of 20 hours per week for 4 weeks)

Student Spouse/Partner (minimum of 6 hours per semester, attach schedule) Fall ___ Spring___ Summer___ Self-Employed Spouse/Partner working a minimum of 20 hours per week (provide notarized statement or tax documentation of self-employment) Spouse/Partner seeking employment or enrolling in school, and the family is requesting an authorization of up to 90 calendar days to provide required documentation of employment or student status.

Section IV - Eligible Child Information List all children for whom you are applying for CCSP Benefits. All children must reside with the Sponsor in order for the benefit to be applied. Documentation will be required to verify each child’s eligibility. Child Name (Last, First, Middle) Birthdate (MM/DD/YYYY) Full- or part-time

enrollment? If your child is currently enrolled in an approved program, please list name below.

If you do not already have an approved child care provider, do you need information about approved providers? Are you receiving any other subsidies? If yes, how much and from whom?


Section V - Statement of Understanding

Statement (Please Initial)

I understand that I must be in an Active Duty status with the USCG in order to be eligible to apply for and receive CCSP benefits. Any change in my status with the USCG must be reported to the Navy CYP Fee Assistance Program caseworker immediately for further review.

I understand that if my Spouse/Partner does not work or attend school as required by the Navy CYP Fee Assistance Program, I am not eligible for the CCSP and this application will be denied.

I understand that I am financially responsible for al l child care costs until a CCSP benefit has been awarded by the Navy CYP Fee Assistance Program for my eligible children.

I understand eligibility for and award of a CCSP benefit does not guarantee approved child care. It is my responsibility to ensure that the Child Care Provider I choose accepts CCSP benefits through the Navy CYP Fee Assistance Program and has completed all appropriate paperwork.

I understand that if my spouse/partner is seeking school enrollment, I must submit his/her school start date and a copy of his or her student school schedule within 90 days. I understand that each time he or she recei ves an updated school schedule or enrollment information, I must provide a copy of the document to the Navy CYP Fee Assistance Program. I understand that my CCSP benefit will be discontinued if I do not provide this documentation by the due date.

By completing this form, I am certifying that I have custody of the child/children for whom I am applying for CCSP and that the child/children reside with me* as the Sponsor named above at his/her address. *Except in a geographical separation situation (e.g., geo-bachelor)

I understand that it is a Federal crime under the United States Code (USC) 18, Section 1001, to make a false statement on thi s form. I understand that if I make a false statement, I may be subject to criminal prosecution and punishment, to include a fine, imprisonment, or both. In addition, I may be subject to administrative punishment to include the termination of my federal employment or disqu alification from participation in the Navy CYP Fee Assistance Program. I understand that misrepresentation or falsifying this information may subject me to prosecution under the Uniform Code of Military Justice (UCMJ) and/or applicable State and Federal Laws. I certify that the above information is true and correct to the best of my knowledge.

Sponsor Signature Date

Privacy Act Statement

Public Law 107-67, § 630 (September, 2001) confers regulatory authority on OPM 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 us e of these Social

Security Numbers will be for identification purposes in determining eligibility for child care subsidy. The primary use of information regarding family

income (copies of pay slips and tax returns), name of current child care provider, copies of the provider's license, statement of compliance, and

information about other child care subsidies is also used to determine 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.

Appendix - Family Application Supporting Documentation Checklist

BAH/Dependency Data Sheet CG Form 4170 (must be signed and dated within 12 months of application)

Leave and Earning Statement (LES) of the Sponsor (most recent)

Spouse/Partner pay statements (minimum of 4 weeks)

Sponsor’s Active Duty Orders or a print out of Direct Access under the Enterprise Menu *Log into Direct Access – Human Resources – Human Resources Reports - Member Information. Once here, a screen will come up,click “Create Report”.

Notarized Power of Attorney (if spouse/partner is authorized to sign documents in Sponsor’s absence )

Federal Tax Return, Form-1040 (if used to satisfy employment requirement for spouse)

Notarized Self Employment Statement (if used to satisfy employment requirement)

The submission of the above documentation will be used in order to determine eligibility for the Child Care Subsidy Program through the Navy CYP Fee Assistance Program. Failure to provide requested information in a timely manner will result in delayed validation of benefits or disapproval of benefits making the Sponsor financially responsible for all child care costs.

Please submit all documents to the

Navy CYP Fee Assistance Program Email: [email protected]

Fax: 1-901-874-6823

Mail to:

Navy CYP Fee Assistance Program 5720 Integrity Drive, Bldg 457

Millington, TN 38055-6540

To expedite application processing, sponsors are strongly encouraged to submit this application and associated documentation via email attachment in PDF format.

mailto:[email protected]


Sponsor Statement of Agreement


Sponsor Name

Sponsor Duty Station Zip Code For Office Use Only – DO NOT ENTER SSN Sponsor ID Number

Child(ren)’s Name(s)

Sponsor’s Initials Statement of Agreement

I understand that I am financially responsible for all child care costs until my child(ren) have been enrolled in a Navy CYP Fee Assistance Program approved child care program. I will notify the Navy CYP Fee Assistance Program in writing to report change of employment should my Spouse/Partner’s schedule and/or employment change and will provide a copy of the proper documentation to support this change in order to continue to participate in the CCSP. I understand that I must notify the Navy CYP Fee Assistance Program if and when my child is no longer enrolled with the qualified child care Provider identified on the Certificate of Eligibility. The CCSP benefit is not transferable to another Child Care Provider. I understand that my CCSP benefit will be placed in an Inactive Status until I have enrolled my child(ren) in an approved Provider’s program. I understand that I must report any upcoming Permanent Change of Station (PCS) move to a Navy CYP Fee Assistance Program caseworker and request to be placed in an Inactive Status prior to a PCS move. Once the PCS move is complete, I understand I must Reactivate my CCSP benefit by completing an updated application packet and submitting required documentation. I understand that I must report any changes in my personal situation or in child care arrangements to the Navy CYP Fee Assistance Program to include, but not limited to, Provider Changes, Rate Changes, Attendance Changes, Adding or Removing a Child from the Program, etc. prior to the action taking place. In instances where a notification is made after the action has occurred, I may be financially responsible for the difference in child care costs based upon what was previously awarded from the date of the action through the first of the month in which notification was made to the Navy CYP Fee Assistance Program. I understand that if my child care Provider’s standing with their state child care licensing authority changes or is revoked, I must report this information to the Navy CYP Fee Assistance Program immediately. This may cause my benefit to become inactive until I have placed my children in an approved child care program or my child care Provider has been reinstated. I understand that if my spouse/partner is seeking employment or school enrollment, that I must submit supporting documentation within 90 days of the date of the Statement of Benefit. I understand that my CCSP benefit will be discontinued if I do not provide this documentation within 90 days. I understand that I will be required to reapply annually for the CCSP through the Navy CYP Fee Assistance Program. I will submit all required documentation in order to maintain eligibility. My CCSP benefit will be recalculated annually OR by the date listed in this Parent Agreement. I understand that if my eligibility changes during the year, I shall contact the Navy CYP Fee Assistance Program immediately.


Sponsor Statement of Agreement


Sponsor’s Initials Statement of Agreement, continued

I understand that unless I have submitted a current, valid Power of Attorney, the Navy CYP Fee Assistance Program caseworker will not discuss benefits, calculations, payments, etc., with my spouse/partner or any other individual other than myself. I understand that any program policy infraction to include, but not limited to, providing incorrect child care cost, knowingly or unknowingly, which causes an overpayment of a CCSP benefit may result in my being disqualified from the program. In addition, repayment of monies received due to this misrepresentation will be required. I understand that Child Care Attendance Record and Subsidy Claim Forms must be properly completed, signed by myself and my child care Provider, and submitted to the Navy CYP Fee Assistance Program monthly. Claim forms submitted for payment must contain an original signature from the Sponsor and the Child Care Provider. Claim forms submitted after 60 days following the end of the period of service will not be eligible for payment resulting in the Sponsor being financially responsible for the child care cost incurred for that period of service.

I understand and agree to the terms and conditions mandated by the Navy CYP Fee Assistance Program and that the CCSP benefit awarded to me for this request will continue based upon the information that was originally provided with my Initial or Renewal Application.

Sponsor Name (print)


Privacy Act Statement Public Law 107-67, § 630 (September, 2001) confers regulatory authority on OPM 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 will be for identification purposes in determining eligibility for child care subsidy. The primary use of information regarding family income (copies of pay slips and tax returns), name of current child care provider, copies of the provider's license, statement of compliance, and information about other child care subsidies is also used to determine 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. Please submit all documents to the Navy CYP Fee Assistance Program Email: [email protected] Fax: 901-874-6823

Mail to: Navy CYP Fee Assistance Program 5720 Integrity Drive, Bldg 457 Millington, TN 38055-6540

To expedite application processing, child care providers are strongly encouraged to submit this all documentation via email attachment in PDF format.


Navy Child and Youth Programs (CYP) Fee Assistance Program

U.S. Coast Guard (USCG) Child Care Subsidy Program (CCSP)

Child Care Attendance and Cost Worksheet

CNICCYP 1700/99 (Rev. 11-20-2019)

Providers or sponsors who misrepresent information used to calculate CCSP benefits may have their benefit

terminated and be subject the Uniform Code of Military Justice (UCMJ) or other legal consequences.


Provider Signature Date

Please submit all documents to the

Navy CYP Fee Assistance Program

Email: [email protected]

Fax: 901-874-6823

Mail to:

Navy CYP Fee Assistance Program

5720 Integrity Drive, Bldg 457

Millington, TN 38055-6540

To expedite processing, child care providers are strongly encouraged to submit documentation via email attachment

in PDF format.

Please complete the information requested in the worksheet to verify the cost for child care services for the child(ren) listed below. This form is to be used whenever the rate for a child has changed.

Section I-Sponsor Information

Sponsor Name Sponsor Rank

Sponsor Duty Station Zip Code FOR OFFICE USE ONLY – DO NOT ENTER SSN

Sponsor ID Number

Section II –Provider Information

Name of Facility or Family Child Care Provider FOR OFFICE USE ONLY Provider ID Number

Physical Street Address

City State Zip

Email Phone Fax

Section III – Attendance and Provider Costs

Indicate the type of care provided for each child listed below and the child care cost. Fees listed as weekly rates will be multiplied by 4.33 to equal monthly rate.

Child’s Name Date of Birth

Check Type of Care

Full Time Part Time Part Day Hourly Before School only After school only Before & After school

Number of days per week Number hours per week Total Cost for Care $

Enrollment/Registration Fees


Check Type of Care





Check Type of Care





Documents

For Office Use Only (DO NOT ENTER SSN): Sponsor ID Number … · 2019-11-21 · signature from the Sponsor and the Child Care Provider. Claim forms submitted after 60 days following