Appendix E

Sample Child Care Subsidy Agreement
Between Employee and Agency or Organization
That Administers Funds

From: (Names of parents or guardians)
Address:
To: (Organization that administers the child care subsidy program)
Address:

Subject: Child Care Subsidy Award Weekly Amount of $_________________ for (insert name of child) to attend the (insert name and address of child care program).

I/We agree to accept the child care subsidy award of $_______________ per week. I/we understand that the award becomes effective (insert date) and remains in effect until (insert date) or the date when the child is no longer enrolled in the child care program named in this agreement, or the date I/we leave the agency, whichever occurs first. I/we agree to notify (name of Organization) if and when our child is no longer enrolled at (insert name of child care program).

I/we agree to submit a new tax return by April 15th. I/we understand any changes to my award based on my/our tax return will be effective May 1st.

I/we understand I/we will be billed by the (insert name of child care provider) for the prevailing child care rate. If the child care rate is increased during the award period, we understand the amount of the award may not change.

Parent Signature: ____________________________    Date: _______________

Parent Signature: ____________________________    Date: _______________

To activate your award, return this form to:

(Insert name and address of organization administering the program)

Your child care subsidy will not become effective unless this form is returned to the organization named above. It verifies your child will be enrolled in the program you indicated on your application form and you agree to report the events listed above.