University of Minnesota Child Care Center (UMCCC) by ftb12802

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									Rev. 6/10

Child’s name____________________________________________________________________________
                          Last                                   First
                        University of Minnesota Child Care Center (UMCCC)
                               REDUCED FEE APPLICATION FORM
                            (Gross annual family income less than $93,841)

GROSS ANNUAL FAMILY INCOME is all income before deductions of a group of related or unrelated
individuals living together as an economic unit. This form must be submitted before the fee for child care
service can be assessed at less than the highest rate. This information is collected upon enrollment, and three
times a year thereafter. Each February, W2 forms must be attached. Each May and upon enrollment, a copy of
the 1040 or equivalent income tax form must be attached. In October, no supporting documentation is
necessary unless requested. Income information will be kept private and confidential and will only be shared by
UMCCC administrative staff with the Department of Audits or other government agencies if necessary. You
may refuse to provide this information but failure to do so will result in your fee being assessed at the highest
rate.

If parents have a formal, court ordered, joint custody agreement in the case of divorce or legal separation, both
gross annual family incomes must be reported, along with a copy of the court order. Both parents must sign this
form. Fees will be based on 70% of the combined income of both households

                                ACTUAL 2009 INCOME (1/1/2009-12/31/2009)

                   Parent A                      Parent B                                    total
Salary                                      +

Other Income                                +                              =




ONLY FILL OUT THE ESTIMATED INCOME PORTION OF THIS FORM IF YOU ANTICIPATE YOUR 2010 INCOME TO
BE 10% GREATER OR LESS THAN IT WAS IN 2009. IF IT WILL CHANGE BY LESS THAN 10% SIGN BELOW AND
SUBMIT.
                                   Amended Gross Annual Family Income
                                Estimated 2010 INCOME (1/1/2010-12/31/2010)

                   Parent A                      Parent B                                    total
Salary                                      +

Other Income                                +                              =


By signing below I/we affirm to the best of my/our knowledge, the above information is accurate and true. I/We
understand it is my/our responsibility to inform UMCCC if my/our gross annual family income changes by more
than 10% from the previous year by completing the Amended Gross Annual Family Income portion of this
form. Fees will be based on estimated income on the first billing period following the receipt of this form by
UMCCC. I/We agree to report any further income changes as soon as they occur. I/We understand that failure
to report an income increase of 10% or more will result in a fee adjustment retroactive to the date of the last
income information provided, but no refund will be provided if I/We overestimate.

____________________________ __________ ____________________________ ____________
      Parent A               date              Parent B                date

                                                UMCCC Use Only
  Fee: S       R    M       H                                     Effective_______________________________

  Authorized Signature:_________________________________________ Date: ________________________________

								
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