Government of Guyana
Ministry of Human Services and Social Security
Application for Child Care Subsidy for Essential Workers
PLEASE COMPLETE ALL SECTIONS WHERE APPLICABLE
Applicant Information
First Name
Last Name
Date of Birth
-
Year
-
Month
Day
Date
National Insurance Scheme Number
National ID or Passport Number
Citizen Status
Guyanese National
Regularized Migrant
Sex
Male
Female
Address (include Apt. number, Street, Neighbourhood)
Lot Number / Apt number
Street
City/Town
Region
Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Reason for Care (Check as many as possible)
Working
Attending School/Study Time Needed
Free Time needed to psychologically recharge
Time needed to physically rest
Time needed with my spouse/partner
Any other (please specify in space below)
Places of Work/School (if applicable)
Contact Number for Work/School
Please enter a valid phone number.
CO-APPLICANT’S INFORMATION
Please bear in mind that the co-applicant is the parent/co-guardian of the 1 child age 7 or below that will benefit from the child care subsidy programme. Tick the box below if thisis your scenario in order to skip this page
I am a single parent/I am the sole legal guardian of this child
*
Yes
No
Co-Applicant's Information
First Name
Last Name
Date of Birth
-
Year
-
Month
Day
Date
National Insurance Scheme Number
National ID or passport number
Sex
Male
Female
Citizen Status
Guyanese National
Regularised Migrant
Irregular Migrant
Address (include Apt. number, lot number, Street, Neighbourhood)
Lot/Apt. Number
Street
City/Town
Region
Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Reason for Care (Check as many as possible)
Working
Attending School/Study Time Needed
Free Time needed to psychologically recharge
Time needed to physically rest
Time needed with my spouse/partner
Any other (please specify in space below)
Places of Work and designation/School (ifapplicable)
Contact Number for Work/School
Please enter a valid phone number.
CHILDREN’S DETAILS
Include children (under the age of 18 years) of the applicant who live in the same home and who are financially dependent on the applicant. Also include dependents who may be 18 years and older who are disabled or who attend high school/university and are financially dependent.
Number of Children living at Home with the applicant
Sex
Male
Female
Age Range of Child/Children
0-7
8-12
13-17
18+
Is the Child/Children Studying?
Yes
No
If yes, Number of disabled children
Number of children under the custody of the applicant
Sex
Male
Female
Age Range of Child/Children under the custody of the applicant
0-7
8-12
13-17
18+
Is the Child/Children Studying?
Yes
No
Does the Child/Children have disabilities?
Yes
No
If yes, Number of disabled children
LIST CHILDREN REQUIRING CHILD CARE SUBSIDY
Please bear in mind that for the first phase of this programme, ONLY 1 CHILD PER HOUSEHOLD OF AGE 7 OR UNDER QUALIFIES but the Ministry of Human Services and Social Security inquiries about the number of children that may need day care per household or essential worker to improve what we do and create better implemented programmes in the future.
Child's Information
First Name
Last Name
Date of Birth
-
Year
-
Month
Day
Date
Grade (if Applicable)
Name of licensed child care centre
Address of licensed child care centre
Lot Number
Street Address
City/Town
Region
Zip Code
Estimated hours of care needed per month
Estimated costs in day care fees (per term)
How many hours of day care are needed outside ofregular business hours Monday to Friday from 8 a.m. to 5 p.m.?
Does the Child/Children have disabilities?
Yes
No
If yes, please specify
If there was night care available in the city, would you use these services?
Yes
No
Where would you prefer the location of the night careto be?
Near home
Near to work
It does not matter to me
Please specify your needs. Please tick as many options applicable to your circumstances
Evening work shifts
Study time
Complete chores
Run errands
Sleep/rest
Any other, please specify below
Please attach to this form the following documents. APPLICANT - Copy of ID card; Birth certificate for child of age 7 or under; Job letter with salary; Pay slip; Invoice of licensed day care.
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APPLICANT DECLARATION AND ACKNOWLEDGEMENT. I understand that giving false or incomplete information or not advising of any changes in circumstances may result in termination or suspension of funding and the requirement to repay funding that I have received.
I understand that the information Igive on the application form may be verified by a Human Services and Social Security Ministry representative at any time.
I will advise Child Care Subsidy Program for Essential Workers immediately of any changes in personal, financial, or family circumstances that will affect my eligibility for subsidy.
I understand that I may be required to provide additional information in order to confirm any initial and continuing eligibility for Child Care Subsidy. I understand that Children's Services may initiate an investigation relating to my eligibility for Child Care Subsidy.
I understand that relevant personal information may be shared with a licensed child care program, approved early learning program, or family day home agency that I have chosen for the care of my child, including information to identify myself/ourselves, my/ourchild(ren), our address, the amount of subsidy we are eligible to receive andthe subsidy period.
I understand that relevant personal information may be shared with other Government programs and services including my/our financial information, employment information, marital status, telephone numbers, dependents addresses and the amount of subsidy to verify/determine my/our eligibility for other government programs or benefits offered by the Government of Guyana
I/We consent to the release, by Guyana Revenue Authority to an official of the Ministry of Human Services and Social Security of income and expense information and identifying information about me/us and our children or dependents, including any social insurance number(s) from GRA records about me/us. The information will be relevant to, and will be used for the purpose of determining, verifying and/or auditing my/our eligibility for the subsidy and collection of overpayments of subsidy provided for in the Child Care Subsidy Program.
In addition, I/we consent to the disclosure by an official of the Ministry of Human Services and Social Security to a licensed child care program that I/we have chosen for the care of my/ourchild, of information obtained from the Guyana Revenue Authority in accordance with this consent or obtained from other sources, that identifies myself/ourselves, my/our child(ren), our address, the amount of subsidy we are eligible to receive under the Child Care Subsidy Program, together with the subsidy period.
Finally, I/we consent to the disclosure by an official of the Ministry of Human Services and Social Security an official of a department or agency of the Government of Guyana, of information obtained from the Guyana Revenue Authority in accordance with this consent or from other sources, that identifies myself/ourselves, my/our child(ren), our address, our marital status, my/our income and expenses and the amount of subsidy we are eligible to receive under the Child Care Subsidy Program
I declare that I understand the above information on this application and provide my signature as consent
Signature
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