DD Form 2652 Application for Department of Defense Child Care Fees

What Is DD Form 2652?

DD Form 2652, Application for Department of Defense Child Care Fees is a document used by Child Development Services (CDS) patrons to determine the appropriate childcare fees according to the total income of the family. A DD Form 2652 fillable version is available for digital filing and download below or can be obtained through the CDS.

The form - sometimes incorrectly referred to as the DA Form 2652 - was last released by the Department of Defense (DoD) in May 2014 with all previous editions obsolete.

The CDS will ensure that all of the assistance required for completing the form is available to all parents. The information provided in the DD 2652 should be full and correct - a periodic audit from outside of the CDS may review the submitted data. Failure to provide necessary information may lead to having to pay the highest fee range.

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OMB No. 0704-0515
APPLICATION FOR DEPARTMENT OF DEFENSE CHILD CARE FEES
OMB approval expires
(Read Instructions on back before completing form.)
May 31, 2017
The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (0704-0515). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO THE APPROPRIATE CHILD AND YOUTH
PROGRAM REPRESENTATIVE.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; 10 U.S.C.
8013, Secretary of the Air Force; DoD Instruction 6060.02, Child Development Programs; Army Regulation 608-10, Child Development Services;
OPNAV Instruction 1700.9 series, Child and Youth Programs; Marine Corps Order P1710.30E, Children, Youth, and Teen Program (CYTP); Air Force
Instruction 34-248, Child Development Programs; and Air Force Instruction 34-249, Youth Programs, and 34-276, Family Child Care.
PRINCIPAL PURPOSE(S): To collect total family income to determine child care fees. When completed, records are covered by one of the
appropriate SORNs: Department of the Army: http://dpclo.defense.gov/privacy/SORNsIndex/tabid/5915/article/6160/a0608-10-cfsc.aspx;
Department of the Navy: http://dpclo.defense.gov/privacy/SORNsIndex/tabid/5915/article/6527/nm01754-3.aspx;
Department of the Air Force: http://dpclo.defense.gov/privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/5793/f034-af-sva-c.aspx
ROUTINE USE(S): Department of the Army records may be disclosed to civilian health and welfare departments/agencies in emergencies.
Department of the Navy records may be disclosed to local, state and Federal officials involved in child care services, if required, in the performance of
their official duties relating to child abuse reporting and investigations. Department of the Air Force records may be disclosed to civilian health and
welfare departments/agencies in emergency situations.
DoD Blanket Routine Uses 1 (Law Enforcement), 4 (Congressional Inquiries), 6 (Required by International Agreement), 9 (Department of Justice for
Litigation), 12 (National Archives and Records Administration), and 15 (Data Breach Remediation) specifically apply to this system. Other DoD Blanket
Routine Uses found at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx may apply to these records. Any release under a
blanket routine use will be compatible with the purpose of the collection.
DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in application of the highest fee range.
SECTION I - DEPENDENT CHILDREN
2. DATE OF BIRTH
1. NAME OF EACH CHILD
3. AGE
4. CARE REQUESTED (OR ENROLLED)
(LAST, First, Middle Initial)
(YYYYMMDD)
a.
b.
c.
d.
e.
SECTION II - ANNUAL FAMILY INCOME
5. SPONSOR
a. NAME
b. YEARS OF MILITARY/CIVIL SERVICE
(LAST, First, Middle Initial)
c. INCOME
(2) Basic Allowance for Housing
(3) Basic Subsistence
(1) Income Data
(5) Total Income - Sponsor
(4) Other Earned Income
(BAH)
Allowance
(To be completed by
Program Staff)
6. SPOUSE OR OTHER ADULT LIVING IN THE HOME
a. NAME
b. INCOME
(LAST, First, Middle Initial)
8. TOTAL INCOME
7. OTHER EARNED INCOME
(Include income from Blocks 5, 6,
and 7. To be completed by Program Staff.)
SECTION III - CERTIFICATION OF SPONSOR/DESIGNEE
(Required for Category I - IX. Please read the following statement carefully before signing.)
I certify that all of the above information is true and correct and that all family income of the spouse and sponsor is reported. I understand that this
information is being given in order to determine child care fees to be paid and that Federal funds are used to subsidize the cost of child care. I also
understand that the installation commander may verify the information on the application; and that deliberate misrepresentation of this information may
subject me to prosecution under applicable State and Federal laws. See 18 U.S.C. Section 1001.
9. SIGNATURE OF SPONSOR
10. SIGNATURE OF SPOUSE
11. DATE SIGNED
(YYYYMMDD)
SECTION IV - FOR CHILD DEVELOPMENT PROGRAM USE ONLY
14. DATE OF APPROVAL
15. NAME OF CHILD DEVELOPMENT
12. CATEGORY OF APPROVAL
13. AUTHORIZED FEES
PROGRAM OFFICIAL
(YYYYMMDD)
DD FORM 2652, MAY 2014
PREVIOUS EDITION IS OBSOLETE.
Adobe Designer 9.0
OMB No. 0704-0515
APPLICATION FOR DEPARTMENT OF DEFENSE CHILD CARE FEES
OMB approval expires
(Read Instructions on back before completing form.)
May 31, 2017
The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (0704-0515). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO THE APPROPRIATE CHILD AND YOUTH
PROGRAM REPRESENTATIVE.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; 10 U.S.C.
8013, Secretary of the Air Force; DoD Instruction 6060.02, Child Development Programs; Army Regulation 608-10, Child Development Services;
OPNAV Instruction 1700.9 series, Child and Youth Programs; Marine Corps Order P1710.30E, Children, Youth, and Teen Program (CYTP); Air Force
Instruction 34-248, Child Development Programs; and Air Force Instruction 34-249, Youth Programs, and 34-276, Family Child Care.
PRINCIPAL PURPOSE(S): To collect total family income to determine child care fees. When completed, records are covered by one of the
appropriate SORNs: Department of the Army: http://dpclo.defense.gov/privacy/SORNsIndex/tabid/5915/article/6160/a0608-10-cfsc.aspx;
Department of the Navy: http://dpclo.defense.gov/privacy/SORNsIndex/tabid/5915/article/6527/nm01754-3.aspx;
Department of the Air Force: http://dpclo.defense.gov/privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/5793/f034-af-sva-c.aspx
ROUTINE USE(S): Department of the Army records may be disclosed to civilian health and welfare departments/agencies in emergencies.
Department of the Navy records may be disclosed to local, state and Federal officials involved in child care services, if required, in the performance of
their official duties relating to child abuse reporting and investigations. Department of the Air Force records may be disclosed to civilian health and
welfare departments/agencies in emergency situations.
DoD Blanket Routine Uses 1 (Law Enforcement), 4 (Congressional Inquiries), 6 (Required by International Agreement), 9 (Department of Justice for
Litigation), 12 (National Archives and Records Administration), and 15 (Data Breach Remediation) specifically apply to this system. Other DoD Blanket
Routine Uses found at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx may apply to these records. Any release under a
blanket routine use will be compatible with the purpose of the collection.
DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in application of the highest fee range.
SECTION I - DEPENDENT CHILDREN
2. DATE OF BIRTH
1. NAME OF EACH CHILD
3. AGE
4. CARE REQUESTED (OR ENROLLED)
(LAST, First, Middle Initial)
(YYYYMMDD)
a.
b.
c.
d.
e.
SECTION II - ANNUAL FAMILY INCOME
5. SPONSOR
a. NAME
b. YEARS OF MILITARY/CIVIL SERVICE
(LAST, First, Middle Initial)
c. INCOME
(2) Basic Allowance for Housing
(3) Basic Subsistence
(1) Income Data
(5) Total Income - Sponsor
(4) Other Earned Income
(BAH)
Allowance
(To be completed by
Program Staff)
6. SPOUSE OR OTHER ADULT LIVING IN THE HOME
a. NAME
b. INCOME
(LAST, First, Middle Initial)
8. TOTAL INCOME
7. OTHER EARNED INCOME
(Include income from Blocks 5, 6,
and 7. To be completed by Program Staff.)
SECTION III - CERTIFICATION OF SPONSOR/DESIGNEE
(Required for Category I - IX. Please read the following statement carefully before signing.)
I certify that all of the above information is true and correct and that all family income of the spouse and sponsor is reported. I understand that this
information is being given in order to determine child care fees to be paid and that Federal funds are used to subsidize the cost of child care. I also
understand that the installation commander may verify the information on the application; and that deliberate misrepresentation of this information may
subject me to prosecution under applicable State and Federal laws. See 18 U.S.C. Section 1001.
9. SIGNATURE OF SPONSOR
10. SIGNATURE OF SPOUSE
11. DATE SIGNED
(YYYYMMDD)
SECTION IV - FOR CHILD DEVELOPMENT PROGRAM USE ONLY
14. DATE OF APPROVAL
15. NAME OF CHILD DEVELOPMENT
12. CATEGORY OF APPROVAL
13. AUTHORIZED FEES
PROGRAM OFFICIAL
(YYYYMMDD)
DD FORM 2652, MAY 2014
PREVIOUS EDITION IS OBSOLETE.
Adobe Designer 9.0
INSTRUCTIONS
Per Department of Defense Instruction 6060.02, Child Development Programs, this form is utilized to determine fees for DoD Child
Care Programs.
To determine child care fees for your child(ren), or and child(ren) you legally claim as dependents, this from must be completed, signed
and returned to the facility for which your child is enrolling.
Fees are determined based on your Total Family Income (TFI) as defined below. If you choose not to disclose your family income,
your rate for child care will be set at the highest fee level.
Total Family Income (TFI) - For the purpose of determining child care fees in DoD Child Development Programs, total family income is
defined as all earned income including wages, salaries, tips, special duty pay (flight pay, active duty demo pay, sea pay) and active
duty save pay, long-term disability benefits, voluntary salary deferrals, retirement or other pension income including SSI paid to the
spouse and VA benefits paid to the surviving spouse before deductions for taxes. TFI calculations must also include quarters
subsistence and other allowances appropriate for the rank and status of military or civilian personnel whether received in cash or in
kind.
DO NOT INCLUDE alimony, and child support received by the custodial parent, SSI received on behalf of the dependent child,
reimbursements for educational expenses or health and wellness benefits, cost of living (COLA) received in high cost areas, temporary
duty allowances, or reenlistment bonuses.
For households in which unmarried couples or pairs are living as a family, the income for both adults should be used to determine Total
Family Income (TFI).
Sections I, II, and III are to be completed by the sponsor or their designee.
Section I.
1. Provide the last name, first name and middle initial for each child who is receiving care in a DoD child care program.
2. Provide the date of birth for each child who is receiving care in a DoD child care program.
3. Provide the age of each child on the date of application who is receiving care in a DoD child care program.
4. Provide the type of care being request or in which each child is currently enrolled.
Section II.
When completing Section II, include all military and civilian income for both the sponsor and spouse or other adult living in the home.
5.a. Provide the sponsor’s last name, first name and middle initial.
5.b. Provide the total years of military/civilian service as applicable.
5.c.(1) Provide your most recent income data and indicate if income is received weekly, biweekly, monthly or twice per month.
5.c.(2) Provide the current year BAH RT/C. For dual military living in government quarters include BAH RC/T of the senior member
only; in locations where military members receive less than the BAH RC/T allowance, use the local BAH rate; for Defense civilian
OCONUS include either the housing allowance or the value of the in-kind housing.
5.c.(3). Provide the basic subsistence allowance or in-kind equivalent.
5.c.(4) Provide any other earned income.
5.c.(5) To be completed by program staff.
6.a. Provide the last name, first name and middle initial of the spouse or other adult living in the home, who contributes to the welfare
of the child.
6.b. Provide the income of the spouse or other adult living in the home, who contributes to the welfare of the child.
7. Provide any additional income.
8. To be completed by program staff.
Section III.
9. Provide the sponsor's signature.
10. Provide the spouse's or other resident adult's signature.
11. Provide the date of signatures.
DD FORM 2652 (BACK), MAY 2014

Download DD Form 2652 Application for Department of Defense Child Care Fees

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How to Fill out DD Form 2652?

Procedural guidelines and additional information can be found in the Army Regulation 608-10 (Child Development Services) released in July 1997. DD Form 2652 instructions are as follows:

  1. The parents are required to complete only the first three sections of the form.
  2. Section I - Dependent Children - should contain the full names, dates of birth, and ages of all children receiving care under a DoD child care program in Columns 1, 2 and 3. Column 4 requires specifying the types of care being requested or already being received by each of the children.
  3. Section II - Annual Family Income - requires the data on the annual income of a household. Boxes 5a and 5b require the sponsor's full name and the total number of years spent in military service. Box 5c is for providing data on the income of the sponsor.
  4. The information about the sponsor's spouse and other adults living in the same household is provided in Boxes 6a and 6b. Other earned income is disclosed in Box 7.
  5. Box 8 - Total Income - is filled in by the CDS staff. Total Family Income (TFI) should include all military and civilian income earned by both parents, including salaries, wages, tips, voluntarily salary deferrals, etc. Alimony or child support, variable housing allowance and cost of living allowances should not be included in TFI.
  6. Section III - Certification of Sponsor/Designee - requires the signatures of the sponsor and the spouse, as well as the date of filing form.
  7. Section IV is for Child Development Program use only.

The completed form requesting special child care fees should be returned to the CDS for an assignment of the applicable fee category.

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