Child Care Rebate Application Form

08-229 (0315-1540) (Page 2 of 2)

4 24 hour care periods required

Please provide information about the number of 24 hour care periods required (covered by this application), and dates:

Number of periods required: __________

 I understand that the Department of Human Services will release information necessary to administer my

Child Care Benefit and/or Child Care Rebate to my child care service(s) and the Department of Social Services.

I understand there are penalties for giving false or misleading information.

Signature __________________________________ Date / /

What to do next?

 When the form is fully completed and signed give it to your service.

 Your service will forward your application to the Special Child Care Assessment Team in the Department of

Human Services

Service details

Service name ___________________________________________________________

Service CCB Approval ID ___________________________________________________________

Service address ____________________________________

____________________________________ Postcode _________

Service telephone number ( ) _____________________________

Name of contact person _____________________________

Department of Human Services use only

I, ________________________________,

Signature __________________________________ Date / /

Position in organisation