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SAMHSA CCSP Applications

OPM Form 1644

SAMHSA CCSP Monthly Invoice




U.S. Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA) CCSP Frequently Asked Questions (FAQs)



FFA has put together a list of Frequently Asked Questions (FAQs) to help answer questions that SAMHSA employees may have about the SAMHSA Child Care Subsidy Program (CCSP). The questions are grouped into the 3 categories below:


  1. Applying for a subsidy from the SAMHSA CCSP
  2. Determining eligibility for the SAMHSA CCSP
  3. Requirements after receiving a SAMHSA CCSP award


Applying for a Child Care Subsidy from the SAMHSA CCSP


Q: How do I apply for a child care subsidy from SAMHSA CCSP?


A: Complete an HHS-698 Form, Child Care Subsidy Program Application, for the SAMHSA CCSP. SAMHSA employees may download an application from the SAMHSA CCSP website by following this link, SAMHSA CCSP Application.  This is a fillable PDF form.


In addition to submitting a completed application, you must also submit:


  1. A signed and dated copy of your mostrecent federal income tax return.
  2. A copy of your (and your spouse or partner, if applicable)2 most recent Statement of Earnings and Leave (SEL) (paycheck stubs for your spouse or partner, if applicable).
  3. A copy of the your most recent SF-50, Notification of Personnel Action.
  4. A copy of your W-2 Form(s), and your spouse’s W-2 Form(s), if applicable.
  5. Have your child care provider(s) complete an OPM Form 1644.Please note: Your provider does not need to fill out Section IV, Provider’s Financial Institution Information.
  6. A copy of your childcare provider’s current license or proof of compliance with State and/or local child care regulations.
  7. A copy of your child care provider’s rate sheet or fee schedule, that the child care provider gives to parents to show how much they charge for their child care services.
  8. A completed IRS Form W-9 from each of your child care providers.
  9. A copy of the birth certificate for each child that will be participating in the SAMHSA CCSP.



Q: When can a new employee apply for SAMHSA CCSP?

Immediately, upon starting to work for the SAMHSA, as long as the SAMHSA employee does meet all the eligibility criteria.


Q: Where should I send my application to be processed?


A:The application and all of the required supporting document scan be emailed or faxed to Rebecca M. Donnelly, PSC Child Care Coordinator, at the following email address or fax number:


Email Address:Rebecca.Donnelly@psc.hhs.gov

Telephone Number:  (301) 492-4080

Fax Number:(240) 465-0217


Please note that your child care provider should submit all their required forms and supporting documents directly to Ms. Rebecca Donnelly. Your child care provider does not have to give their required forms and other documents to you.


Determining Eligibility for the SAMHSA CCSP


Q: What factors will FFA consider in order to determine if an employee is eligible to receive an award?


A: FFA will follow the guidelines established by the SAMHSA to determine which employees who apply for an award, meet all the eligibility requirements. The eligibility requirements are:


  1. You must be an active full-time SAMHSA employee.
  2. Have a child enrolled in, or will be enrolled in, a licensed or regulated childcare facility, orwith a licensed or regulated home-based childcare provider (licensed and/or regulated by the State and/or local authorities where the child care service is provided).
  3. Your child must have the following relationship to you: a) a biological child who lives with you; b) an adopted child; c) a stepchild; d) a foster child; e) a child for whom a judicial determination of support has been obtained; or f) a child who you are the parent or legal guardian of, and to whose support you make regular and substantial contributions.
  4. Your child must be age 13 or under, or under age 18 if your child is disabled. A disabled child is defined as one who is unable to care for himself or herself based on a physical ormental incapacity as determined by a physician or licensed or certified psychologist.
  5. Have a total family income (TFI) that does not exceed $75,000per year.  TFI is determined by looking at the adjusted gross income (AGI),for yourself and your spouse or partner, if applicable,as reported on the most recent federal income tax return(IRS Form1040,IRS Form 1040A, or IRS 1040EZ).


Q: Will I be notified that I am eligible to receive an award?


A: Yes, FFA will email a SAMHSA CCSP Award Letter and a SAMHSA CCSP Award Agreement to all SAMHSA employees determined to be eligible to receive an award. In addition, FFA will notify all employees who were determined not to be eligible to receive an award and provide the reason(s) for such determination.


Q: What will be the amount of the award?


A:If the SAMHSA employee meets all of the eligibility requirements, including Total Family Income of no more than $75,000, then the child care subsidy benefit will be a weekly amount of $75.00 per child per eligible household (or, if the amount paid for child care is less than $75.00 weekly per child, the lesser amount will be covered).The child care subsidy will be reduced by the amount the participant receives in state, county or local child care subsidies from any other sources.



Requirements After Receiving an Award


Q: Once I receive an award letter, what should I do next?


A: You must fully complete, sign, and date the SAMHSA CCSP Award Agreement included with your SAMHSA Award Letter. You may then fax or email a copy of the signed SAMHSA CCSP Award Agreement to FFA. The fax number for FFA is: (770) 484-9313, and the email address is: pscccsp@1stfinancialassociates.com.


Also, you must also mail the original signed SAMHSA CCSP Award Agreement back to FFA. The mailing address for FFA is:


First Financial Associates


7079 Hayden Quarry RD

Lithonia, GA 30038


Q: How do I notify FFA of the amount incurred for childcare charges for each month?


A: You must send FFA a SAMHSA CCSP Monthly Invoice which will show the total charges incurred for child care services rendered each month. The child care charges should be stated as weekly totals, and the weekly totals should be added to get the total child care expense for each month.  Each week ends on a Friday.  Most months will have 4 weeks. You can determine how many weeks are in a month by counting the number of Fridays in the month.  If the Friday of a week has a date in the next month, then that entire week should not go on the current month’s invoice, it should go on the next month’s invoice. You and your childcare provider must sign the SAMHSA CCSP invoice for each month. If you have more than one (1) childcare provider, you must submit a separate SAMHSA CCSP Monthly Invoice form for each childcare provider.


Q. How can I get a copy of the SAMHSACCSP Monthly Invoice and who will send it to my provider?


A: You may obtain it on our website by following this link: SAMHSA CCSP Monthly Invoice.  The SAMHSA CCSP Monthly Invoice form is a PDF fillable form.  You may complete it online using your keyboard.When you input the weekly child care charges for each week, the form will automatically calculate the monthly invoice total.Once you have completed the monthly invoice form, you and your child care provider may sign it with a digital signatureif you have an Adobe digital signature. If you do not have an Adobe digital signature, then you can print the completed invoice, sign it and have your childcare provider sign it. 


Q. If I change child care providers when do I notify FFA, and what documents should be submitted?


A:You must notify the PSC Child Care Coordinator (Rebecca Donnelly) immediately.  Your new child care provider must submit a completed Form OPM 1644, and a copy of the providerís current license or proof of compliance with state and/or local child care regulations. In addition, the new child care provider must submit the following other documents to the PSC Child Care Coordinator before any CCSP payments can be made to the new child care provider: IRS Form W-9, and a copy of the new child care providerís rate sheet that shows how much they charge for child care services.  FFA will not be able to process your monthly invoice without these items.


Q: Once I have been determined eligible to receive an award, do I have to submit a new application each year?


A: No. However, you will need to re-certify your continued eligibility and we will need to determine your current subsidy percent annually no later than April 30th of each year.  In order for us to determine your continued eligibility to receive an SAMHSA CCSP award, and the correct subsidy percent, each year you must complete the recertification process and submit copies of the following documents to the PSC Child Care Coordinator (Rebecca Donnelly): HHS-698 Form, OPM Form 1644, your most recent signed and dated federal income tax return, two most recent pay statements (for you and your spouse, if applicable), a copy of your IRS Form W-2 (also your spouse’s W-2, if applicable), your most recent SF-50, and a current copy of your child care provider’s license (if the previous license has expired), a current copy of your child care provider’s rate sheet, and if you are adding a new child to the SAMHSA CCSP, we will need a copy of the birth certificate for each new child added.








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