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DOCUMENTS ENCLOSED ARE SUBJECTTO THE PRIVACY ACT OF 1974
Contents shall not be disclosed, discussed, or shared withindividuals unless they have a direct need-to-know in theperformance of their official duties. Deliver this/thesedocument(s) directly to the intended recipient. DO NOT drop off with a third-party.
To be used onall documents
containing personalinformation
The enclosed document(s) may contain personal or privileged information and should be treatedas “For Official Use Only.” Unauthorized disclosure of this information may result in CIVIL andCRIMINAL penalties. If you are not the intended recipient or believe that you have received thisdocument(s) in error, do not copy, disseminate or otherwise use the information and contact the owner/creator or your Privacy Act officer regarding the document(s).
DD FORM 2923, SEP 2010
Privacy Act Data Cover Sheet
Privacy Act DataCover Sheet
CNICCYP 1700/97 (Rev. 11.20.2019) Page 1 of 2
Navy Child and Youth Programs (CYP) Fee Assistance Program Child Care Subsidy Program (CCSP) Provider Information Update Form
Administrative Use Only: Provider ID Number Name of Facility or Family Child Care Provider
This form must be used by qualifying child care providers to update information on file with the Navy CYP Fee Assistance Program. Update any information fields that have changed. Please leave blank any information fields that have not changed.
Section I – Provider Information Name of Facility or Family Child Care Provider Program Type
Doing Business As (DBA) if applicable
Physical Street Address
City State Zip
Remit To/Mailing Address (if different than physical address)
City State Zip
Primary Contact Name (Last, First) and Title
Primary Phone Number (include area code) Fax Number
Primary Email
Secondary Contact Name (Last, First) and Title
Secondary Phone Number (include area code) Email
Section II – Days and Hours of Operation Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total Hours
Section III – Program Oversight Check any changes that apply to your program oversight. *Please submit a copy of the applicable documentation.
There has been a change to my center/program’s licensing/certification status.
Obtained* Revoked Suspended Expired Date of Change
There has been a change to my center/program’s certification status.
Obtained* Revoked Suspended Expired Date of Change
There has been a change to my center/programs accreditation status.
Obtained* Revoked Suspended Expired Date of Change
Provide any relevant details or information. A CCSP caseworker will reach out to your contact for additional information if needed.
CNICCYP 1700/97 (Rev. 11.20.2019) Page 2 of 2
Section IV – Program Rates and Fees
List any updates or changes to your standard child care rates below. This is the amount charged PER CHILD in each
age group listed below for the selected time period. Providers may submit one rate change per year. Rate changes must be submitted at least 15 days prior to the effective date of the change. Age Group/ Type of Care
0-12Months
13-24Months
2 Years 3-5Years
School Age Before
School Age After
School Age- Before & After
Full Day-School Age
Summer Camp
Monthly (Weekly Cost X 4.33)
Hourly Rate
Daily Rate
Weekly Full Time Rate
Weekly Part Time Rate Enrollment Fee
Registration Fee
Does your program offer a
multiple child discount?
Yes No If yes, provide discount information.
Does your program offer any other type of discount?
Yes No If yes, please explain.
Does your program charge any other fees that are not listed above? If so, please list the fee, frequency, and amount.
Section V – Certification of Child Care Provider
I certify that the above information is true and correct to the best of my knowledge. I understand that the Navy CYP Fee Assistance Program may reach out to me for additional documentation or information on the updates listed on this form.
Provider
Signature
Date
Privacy Act Statement Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal Government furnish a
Social Security Number or Tax Identification Number (TIN). This is an amendment to Title 31, Section 7701. The primary use of information regarding family income (copies of pay statements and tax returns), name of current child
care provider, copies of provider's license, letter of Accreditation, statement of compliance, and information about other child care subsides is also used to determine eligibility for Fee Assistance. Disclosure of the above information is
voluntary, but failure to provide all of the requested information may result in the denial of your application.
Please submit all documents to the
Navy CYP Fee Assistance Program
Email: [email protected]
Fax: 901-874-6823
Mail to:
Navy CYP Fee Assistance Program
5720 Integrity Drive, Bldg 457
Millington, TN 38055-6540
To expedite application processing, child care providers are strongly encouraged to submit this application and associated documentation via email attachment in PDF format.
