Childcare Fund Application

Personal Information

Name

First Name

Last Name

UMass Chan ID Number:

Daytime Phone:

(###)

###

####

Department:

Preferred Email Address:

Home Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Household and Income Details

Number of children in your household:

Number of adults in your household:

Hours worked per week at UMass Chan:

Adjusted gross household income from your last filed tax return (2023 for most people):

Estimated adjusted gross household income for 2024:

If you think your 2024 income will be less than your reported 2023 income from your tax form, please explain why below. Also, please share any information that would help us better understand your income or expenses.

Childcare Arrangement and Cost Information

Please list each child for whom you are applying for assistance and their dates of birth. If your child is not yet born, please write "Child not born yet" in the name field and put the child's anticipated birth date in the date field.

Child's first and last name:

Date of birth:

YYYY

Child's first and last name:

Date of birth:

YYYY

Child's first and last name:

Date of birth:

YYYY

Child's first and last name:

Date of birth:

YYYY

Child's first and last name:

Date of birth:

YYYY

Childcare Providers

Please list all childcare providers you plan to use and their license numbers (or social security numbers, for nannies or babystitters). If your child is not born yet and/or you have not yet chosen a childcare provider, please write "Provider not yet chosen" under "Provider's Name." Please note that you will be required to provide the license number or social security number of the childcare provider when submitting for reimbursement for your childcare expenses in the coming year. Even if you don't know who your childcare provider will be, you must provide an estimate of your monthly expenses in order to receive an award. It's fine to take an educated guess.

Provider's name:

Arrangement confirmed:

Yes