Application: Child Day Care Subsidy

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

Student Information

Student ID# *

First Name *

Middle Initial

Last Name *

Email Address *

Phone Number *

Street Address *

City *

State *

Zip Code *

Department/ Program *

Campus Box

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.