WORKSHEET
Child Care Scholarship -2014
The Child Care Scholarship Fund is an NYU program established to assist eligible full-time 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.
WORKSHEET
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 2013is less than $130,000.
You have a child who is younger than five (5) years on December 31, 2013.
WORKSHEET
Child Care Scholarship – 2014
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
WORKSHEET
Child Care Scholarship – 2014
Employee & Family Information
Applicant Name: First: Last: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: ( )
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 Gross Income Estimated
for 2013
Self
Please scan and attach:
WORKSHEET
Child Care Scholarship – 2014
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.
WORKSHEET
Child Care Scholarship – 2014
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 on-line 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 Relative Care Family Child Care
WORKSHEET
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: ____ / ____ / _____ To: ____ / ____ / _____ Period 2 - From: ____ / ____ / _____ To: ____ / ____ / _____ T o : _ _ _ _ / _ _ _ _ /
Please enter the dates (mm/dd/yyyy) you require this care provider:
WORKSHEET
Child Care Scholarship – 2014
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 on-line 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 Relative Care Family Child Care
WORKSHEET
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: ____ / ____ / _____ To: ____ / ____ / _____ Period 2 - From: ____ / ____ / _____ To: ____ / ____ / _____
Please enter the dates (mm/dd/yyyy) you require this care provider:
WORKSHEET
Child Care Scholarship – 2014
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.)
WORKSHEET
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?
