Childcare Expense Verification

APPLICANT/TENANT CERTIFICATION FOR CHILDCARE EXPENSES

I/We hereby certify that the following represent true and accurate statements regarding our household circumstances related to childcare: Child/Children cared for are under the age of 13 years of age.

Such care enables a family member to do one of the following:*

Work
Seek Employment
Attend Vocational or Academic Courses (self sufficiency)

Family Member’s Name*

First Last

Email Address*

Employer or Institution*

Employer or Institution Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Hours Worked

Per

week
month

OR Course

Hours at School

per week

Date*

Childcare costs are not paid to anyone living in our household
I/We do not receive reimbursement for child care costs from any agency or individual outside the household.

I/We recognize that the above statements are subject to third party verification.

VERIFICATION OF AMOUNT PAID FOR CARE OF CHILDREN OR DEPENDENT PERSONS

Your childcare provider is required to fill out this form and submit it with your application. You may download the form here: Verification of Amount of Childcare

I have downloaded the form "Verification of Amount of Childcare" from the link above.*

Yes
No

IMPORTANT: THIS FORM MUST BE EXECUTED WHENEVER A DEDUCTION FROM INCOME IS MADE. WARNING: TITLE 18 SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF THE UNITED STATES GOVERNMENT. ALSO AMOUNTS RECEIVED FROM PROVIDING CHILDCARE ARE REPORTABLE TO THE INTERNAL REVENUE SERVICE (IRS).

Childcare Expenses

APPLICANT/TENANT CERTIFICATION FOR CHILDCARE EXPENSES

VERIFICATION OF AMOUNT PAID FOR CARE OF CHILDREN OR DEPENDENT PERSONS