Dependent Care Voucher Program: JHU EMPLOYEE INFORMATION

This form may be filled out on your computer, printed and mailed or hand carried to WORKlife Programs, The Johns Hopkins University, 1101 E. 33rd St., Suite C100, Baltimore, MD 21218. We must have the signed original for our files.

DEMOGRAPHIC INFORMATION:

Last name: First: Middle Initial:

SS#: - -

Date of birth: (mm/dd/yyyy) / /

Race / ethnic group:
African American
Asian/Pacific Islander
Native American
Hispanic/Latino
Caucasian
Other  

Marital status:
Married
Significant Other
Separated
Divorced
Widowed
Single
Other

Sex: Male Female

Education: (What is the highest level of education you have attained?)
Elementary
Junior High (6-8 years)
High School (9-12 years)
2-year College (13-14 years)
4-year College (14-15 years)
Masters degree (17-19 years)
Non-medical doctorate (20-24 years)
Medical doctorate (20-24 years)
More than 24 years

CONTACT INFORMATION:

HOME:

Street: Apt #:
City: State: Zip Code:
E-mail:
Home Phone: - - Fax: - -
Pager: - -

WORK:

Position title:

University Division: (Use the drop down arrow to find your division.)
  Academic Center/Support Svcs Arts and Sciences Engineering Homewood Schools Svcs Hygiene and Public Health JHU Press Medicine Nursing Peabody SAIS University Admin

Department:

Room # / building name:

Work Phone: - -

Employment date: (mm/dd/yyyy)

/ /

SPOUSE / PARTNER INFORMATION: (To qualify for this program, verification that your spouse/partner is must be working or enrolled in school must be provided.)

NAME:

Last: First: Middle Initial:

Employer:

Work address:

Street: City:
State: Zip code:
Work phone: - -

COLLEGE / UNIVERSITY / TRAINING PROGRAM:

Full time Part time

DEPENDENT INFORMATION: Note: Dependent must meet Internal Revenue Service requirement to be eligible. This requirement states that dependent must reside in your home a minimum of 8 hours per day and you must be providing more than 50% of their support.

Last name: First: Middle Initial:

Date of birth: (mm/dd/yyyy) / /

Sex:
Male Female

As proof of family income and dependents, attach a copy of your most current, complete and signed Federal Tax Form (1040). (Do not submit W-2 statement of Earnings). If you and your spouse/partner file separately, both tax statements must be attached. Should current income be less than reflected on your tax documents due to divorce, separation or death of spouse/partner, the JHU employee's current salary will be used as the income guideline. Please initial here if this is the case: ______.

By signing this form, I agree to the following:

1. I give the Office of Work, Life and Engagement permission to verify my employment, my salary, my family income, dependents and information reported on my enclosed tax return.
2. I give the Office of Work, Life and Engagement permission to verify my spouse/partner employment or will provide proof of spouse/partner enrollment in school.
3. I understand that it is my responsibility to report any change in my employment status, any change of address, any change of dependent care, and any change in family income. If I terminate employment but owe money to the Voucher Program, money owed may be deducted from my final paycheck.
4. I understand that it is my responsibility to submit a copy of my Federal tax return each year by April 30th and that failure to do so may result in my disqualification from the scholarship program.
5. The employee agrees that they will disclose to the Office of Work, Life and Engagement any additional childcare funding they may receive from the State of Maryland.
6. I understand that providing inaccurate information may result in disqualification from this program.
7. I understand that $5,000 is the combined total allowed for dependent care assistance from the Dependent Care Reimbursement Account, scholarships for Downtown Baltimore Child Care or The Johns Hopkins Child Care and Early Learning Center, the Dependent Care Voucher Program and the Sick, Emergency, and Back-up Care Program.
8. I understand that changes in the Voucher awards may be necessary to ensure that funds are available throughout the year.
9. I understand that the selection of a dependent care provider is my exclusive responsibility. Except for verifying license status at the time of application, the university does not screen or check the background, status, or qualifications of the dependent care provider. This is my responsibility as a parent or family member.
10. I agree to abide by the policies stated in the Dependent Care Voucher Program Policies and Procedures document and the Provider Enrollment form.
11. I understand that care providers who abuse this program will be reported to their appropriate licensing agency.
12. I understand that employees who abuse this program will be subject to termination and possible legal action.

Signature ________________________________ Date _______________________________