2020 Childcare Recertification Form
Please complete all items below and attach all required documents before clicking "submit". You will not be able to successfully submit your recertification form until all required items are complete.
By checking the box below, I certify that I understand it is a crime to make a false statement on this form. If I make a false statement, I may be subject to criminal prosecution and punishment including a fine, imprisonment, or both. Federal employees may also be subject to administrative punishment, including termination of federal employment. I also certify I am still employed at the federal agency selected below.
Agriculture: Food and Nutrition Service (FNS)
Agriculture: Research, Education and Economics (REE)
Court Services and Offender Supervision Agency: CSOSA
Court Services and Offender Supervision Agency: DC Pretrial Services Agency
EPA: Environmental Protection Agency (EPA)
Federal Retirement Thrift Investment: Federal Retirement Thrift Investment Board
HHS: Centers for Disease Control and Prevention (CDC)
HHS: Health Resources and Services Administration (HRSA)
HHS: National Institutes of Health (NIH)
Homeland Security: Customs and Border Protection (CBP)
Homeland Security: Secret Service
HUD: Department of Housing and Urban Development (HUD)
National Labor Relations Board (NLRB)
National Science Foundation (NSF): National Science Foundation (NSF)
PBGC: Pension Benefit Guaranty Corporation
State: Department of State
Treasury: IRS Office of Chief Counsel (IRSOCC)
Home Street Address
Address Line 2
Cell Phone Number
Personal Email Address
Work Email Address
Please attach a complete copy of your 2019 Federal Tax Return (1040, 1040A, or 1040EZ) as submitted to the U.S. Internal Revenue Service, including any schedules filed. You do not need to send your state return. File format MUST bePDF.
If you are married filing separately for your 2019 Federal Income Tax, please attach a complete copy of your spouse's 2019 Federal Tax Return (1040, 1040A, or 1040EZ) as submitted to the U.S. Internal Revenue Service, including any schedules filed. You do not need to send your state return. File format MUST be PDF.
Please attach a copy of your most recent leave and earnings statement. If your tax filing status is "married" (filing jointly OR filing separately) please also attach your spouse's most recent leave and earnings statement/pay stub. File format MUST be PDF.
Please attached a complete, signed
OPM Form 1643
. File format MUST be PDF.
Please attach a current schedule of fees from your childcare provider. File format MUST be PDF.