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Application: Child Day Care Subsidy
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Criteria for Eligibility
Please select ALL that apply.
To be considered for the Child Day Care Subsidy, a student must meet ALL the listed criteria:
Be enrolled full time in a Washington University PhD degree program at the start of the award period.
Be the parent of a child five years old or younger, or a child with special needs under the age of 19.
Incur child day care tuition expenses from services provided by a licensed provider.
Apply for scholarships and aid at your chosen, licensed provider before applying for the Washington University child day care subsidy.
Provide proof of any aid awarded by a licensed provider.
Be making satisfactory academic progress, as defined by Washington University.
Utilize child day care services because you are a single student, or if married or have a partner, because your spouse or partner is either a student (enrolled full time in an undergraduate or graduate degree program) or employed outside the home for a minimum of 20 hours per week.
I attest that I have met all the above criteria and am eligible to apply for the Child Day Care Subsidy.
*
Yes
No
Student Information
Student ID#
*
First Name
*
Middle Initial
Last Name
*
Email Address
*
Phone Number
*
Street Address
*
City
*
State
*
Zip Code
*
Department/ Program
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Campus Box
Subsidy Request Information
For which semester(s) are you requesting the Child Day Care Subsidy?
Fall
Spring
Year of Fall Semester
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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Year
Year
2019
2020
2021
2022
2023
Year of Spring Semester
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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Year
Year
2019
2020
2021
2022
2023
Number of credit hours in which you will be enrolled each semester
Fall
*
Spring
*
Marital Status:
*
Married or Partner
Single
Divorced
Widowed
Other...
Marital Status: Other...
Partner's Information
First Name
*
Middle Initial
Last Name
*
Is your partner employed?
*
Yes
No
Number of hours your partner works per week:
*
Is your partner a student?
Yes
No
Is your partner a student at Washington University in St. Louis?
*
Yes
No
Partner's Student ID#
*
Name of Institution
Number of credit hours in which your partner will be enrolled each semester
Fall
Spring
Dependent Child Information
Child: First Name
*
Child: Last Name
*
Child: DOB
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
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Year
Year
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2013
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2015
2016
2017
2018
2019
2020
2021
2022
Child: Age
*
Monthly day care tuition for child
*
Name of day care provider
*
License Number
*
Day care provider phone number
*
Day care provider address
Street Address
*
City
*
State
*
Zip Code
*
I have additional dependents who need assistance from the child day care subsidy
*
Yes
No
Second Dependent Child Information
Child: First Name
*
Child: Last Name
*
Child: DOB
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
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5
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Year
Year
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Child: Age
*
Monthly day care tuition for child
*
Name of day care provider
*
License Number
*
Day care provider phone number
*
Day care provider address
Street Address
*
City
*
State
*
Zip Code
*
I have an additional dependent who need assistance from the child day care subsidy
*
Yes
No
Third Dependent Child Information
Child: First Name
*
Child: Last Name
*
Child: DOB
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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30
31
Year
Year
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Child: Age
*
Monthly day care tuition for child
*
Name of day care provider
*
License Number
*
Day care provider phone number
*
Day care provider address
Street Address
*
City
*
State
*
Zip Code
*
Other Sources of Income
Do you have additional sources of income?
*
Yes
No
Name of source
Monthly amount
*
Initial Each Statement of Understanding
By typing my initials next to each Statement of Understanding, I confirm that all information included in this form is true and complete.
I certify that I meet all the eligibility criteria listed in the instructions for this form.
*
I understand that changes in my enrollment status or in my child’s day care arrangements may result in the reduction or cancellation of my award.
*
I understand that it is my responsibility to report to the Graduate School any changes in my child day care arrangements or costs during the semester(s) I am awarded the Child Day Care Subsidy.
*
I certify that all statements relating to this application are complete and correct to the best of my knowledge and I understand that intentional misrepresentation may result in cancellation and my repayment of the Child Day Care Subsidy.
*
I understand that the Child Day Care Subsidy is taxable income to me, and subject to taxes but not withholding.
*
I authorize Washington University in St. Louis to verify the enrollment of my child(ren) in the day care facilities listed herein.
*
Tax Information
PLEASE BLACK OUT ALL SOCIAL SECURITY NUMBERS
I Plan to Submit my Tax Return Information to Susan Shannon by:
In person: Danforth Campus | Cupples II | Suite 204
Postal mail: Graduate School | Washington University in St. Louis | Campus Box 1187 | One Brookings Dr., St. Louis, MO 63130
I am a:
Domestic Student
International Student
Domestic Students Should Submit
copies of their, and if applicable, their spouse's or partner’s signed federal income tax returns from the previous year (1040, 1040A, 1040EZ, 1040NR, 1040NR-EZ, or Form 8843) and/or a previous year Non-Filing Statement Submit the Non-Filing Statement if you/your spouse/partner were not required to submit tax returns based on IRS income requirements.
International Students Should Submit
submit copies of their and their spouse's or partner’s signed federal income tax returns from the previous year (1040, 1040NR, 1040NR-EZ, or Form 8843). U.S. Internal Revenue Service guidelines require all international students to file a tax return. If you did not reside in the United States last year, please submit a statement to that effect.
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