DD 2652 Application for DoD Child Care Fees

OMB No.
OMB approval expires

APPLICATION FOR DEPARTMENT OF DEFENSE CHILD CARE FEES
(Read Instructions on back before completing form.)

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (XXXX-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO:
OFFICE OF FAMILY POLICY/CHILDREN AND YOUTH, 4800 MARK CENTER DRIVE, SUITE 03G15, ALEXANDRIA, VA 22350-1400

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; 10 U.S.C.
8013, Secretary of the Air Force; DoD Instruction 6060.02, Child Development Programs; Army Regulation 608-10, Child Development Services;
OPNAV Instruction 1700.9 series, Child and Youth Programs; Marine Corps Order P1710.30E, Children, Youth, and Teen Program (CYTP); Air Force
Instruction 34-248, Child Development Programs; and Air Force Instruction 34-249, Youth Programs, and 34-276, Family Child Care.
PRINCIPAL PURPOSE(S): To collect total family income to determine child care fees. When completed, records are covered by one of the
appropriate SORNs: Department of the Army: http://dpclo.defense.gov/privacy/SORNsIndex/tabid/5915/article/6160/a0608-10-cfsc.aspx;
Department of the Navy: http://dpclo.defense.gov/privacy/SORNsIndex/tabid/5915/article/6527/nm01754-3.aspx;
Department of the Air Force: http://dpclo.defense.gov/privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/5793/f034-af-sva-c.aspx
ROUTINE USE(S): Department of the Army records may be disclosed to civilian health and welfare departments/agencies in emergencies.
Department of the Navy records may be disclosed to local, state and Federal officials involved in child care services, if required, in the performance of
their official duties relating to child abuse reporting and investigations. Department of the Air Force records may be disclosed to civilian health and
welfare departments/agencies in emergency situations.
DoD Blanket Routine Uses 1 (Law Enforcement), 4 (Congressional Inquiries), 6 (Required by International Agreement), 9 (Department of Justice for
Litigation), 12 (National Archives and Records Administration), and 15 (Data Breach Remediation) specifically apply to this system. Other DoD Blanket
Routine Uses found at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx may apply to these records. Any release under a
blanket routine use will be compatible with the purpose of the collection.
DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in application of the highest fee range.

SECTION I - DEPENDENT CHILDREN
1. NAME OF EACH CHILD (LAST, First, Middle Initial)

2. DATE OF BIRTH
(YYYYMMDD)

3. AGE

4. CARE REQUESTED (OR ENROLLED)

a.
b.
c.
d.
e.

SECTION II - ANNUAL FAMILY INCOME
5. SPONSOR

N E E D S

a. NAME (LAST, First, Middle Initial)
c. INCOME
(1) Income Data

(2) Basic Allowance for Housing
(BAH)

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b. YEARS OF MILITARY/CIVIL SERVICE

(3) Basic Subsistence
Allowance

(4) Other Earned Income

(5) Total Income - Sponsor
(To be completed by
Program Staff)

6. SPOUSE OR OTHER ADULT LIVING IN THE HOME
a. NAME (LAST, First, Middle Initial)

b. INCOME

7. OTHER EARNED INCOME

8. TOTAL INCOME (Include income from Blocks 5, 6,
and 7. To be completed by Program Staff.)

SECTION III - CERTIFICATION OF SPONSOR/DESIGNEE
(Required for Category I - IX. Please read the following statement carefully before signing.)
I certify that all of the above information is true and correct and that all family income of the spouse and sponsor is reported. I understand that this
information is being given in order to determine child care fees to be paid and that Federal funds are used to subsidize the cost of child care. I also
understand that the installation commander may verify the information on the application; and that deliberate misrepresentation of this information may
subject me to prosecution under applicable State and Federal laws. See 18 U.S.C. Section 1001.
9. SIGNATURE OF SPONSOR

10. SIGNATURE OF SPOUSE

11. DATE SIGNED (YYYYMMDD)

SECTION IV - FOR CHILD DEVELOPMENT PROGRAM USE ONLY
12. CATEGORY OF APPROVAL

13. AUTHORIZED FEES

14. DATE OF APPROVAL
(YYYYMMDD)

DD FORM 2652, 20140423 DRAFT

PREVIOUS EDITION IS OBSOLETE.

15. NAME OF CHILD DEVELOPMENT
PROGRAM OFFICIAL
Adobe Designer 9.0

INSTRUCTIONS
Per Department of Defense Instruction 6060.02, Child Development Programs, this form is utilized to determine fees for DoD Child
Care Programs.
To determine child care fees for your child(ren), or and child(ren) you legally claim as dependents, this from must be completed, signed
and returned to the facility for which your child is enrolling.
Fees are determined based on your Total Family Income (TFI) as defined below. If you choose not to disclose your family income,
your rate for child care will be set at the highest fee level.
Total Family Income (TFI) - For the purpose of determining child care fees in DoD Child Development Programs, total family income is
defined as all earned income including wages, salaries, tips, special duty pay (flight pay, active duty demo pay, sea pay) and active
duty save pay, long-term disability benefits, voluntary salary deferrals, retirement or other pension income including SSI paid to the
spouse and VA benefits paid to the surviving spouse before deductions for taxes. TFI calculations must also include quarters
subsistence and other allowances appropriate for the rank and status of military or civilian personnel whether received in cash or in
kind.
DO NOT INCLUDE alimony, and child support received by the custodial parent, SSI received on behalf of the dependent child,
reimbursements for educational expenses or health and wellness benefits, cost of living (COLA) received in high cost areas, temporary
duty allowances, or reenlistment bonuses.
For households in which unmarried couples or pairs are living as a family, the income for both adults should be used to determine Total
Family Income (TFI).
Sections I, II, and III are to be completed by the sponsor or their designee.
Section I.
1. Provide the last name, first name and middle initial for each child who is receiving care in a DoD child care program.
2. Provide the date of birth for each child who is receiving care in a DoD child care program.
3. Provide the age of each child on the date of application who is receiving care in a DoD child care program.
4. Provide the type of care being request or in which each child is currently enrolled.
Section II.

N E E D S

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When completing Section II, include all military and civilian income for both the sponsor and spouse or other adult living in the home.
5.a. Provide the sponsor’s last name, first name and middle initial.
5.b. Provide the total years of military/civilian service as applicable.
5.c.(1) Provide your most recent income data and indicate if income is received weekly, biweekly, monthly or twice per month.
5.c.(2) Provide the current year BAH RT/C. For dual military living in government quarters include BAH RC/T of the senior member
only; in locations where military members receive less than the BAH RC/T allowance, use the local BAH rate; for Defense civilian
OCONUS include either the housing allowance or the value of the in-kind housing.
5.c.(3). Provide the basic subsistence allowance or in-kind equivalent.
5.c.(4) Provide any other earned income.
5.c.(5) To be completed by program staff.
6.a. Provide the last name, first name and middle initial of the spouse or other adult living in the home, who contributes to the welfare
of the child.
6.b. Provide the income of the spouse or other adult living in the home, who contributes to the welfare of the child.
7. Provide any additional income.
8. To be completed by program staff.
Section III.
9. Provide the sponsor's signature.
10. Provide the spouse's or other resident adult's signature.
11. Provide the date of signatures.

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