An application for a training reimbursement shall be accepted only for approved training successfully completed not more than 180 days before the date of this application request. Applicant must hold a current Maryland Child Care Credential of Level Two or higher. INSTRUCTIONS: Complete all information in the spaces provided. All applications must be accompanied by required documentation. Incomplete applications will not be processed. Personal Information Applicant's First Name * Applicant's Middle Name Applicant's Last Name * Applicant's Maiden Name Last four digit of Social Security Number * Annual Family Income * Federal Tax Form 1040 - Line 22 CCATS/Party ID# * Mailing Address * Country * United States Address 1 * Address 2 City * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * Daytime Phone * Alternate Phone Email Address * I am a * Check the appropriate box. I am a Family Child Care Provider I work in a Child Care Center Center Name License Training Information: Only training completed within the past SIX months may be reimbursed. Attach copies of : Receipt of payment indicating the amount paid for the training Certificate of successful completion, grade slip or transcript. (Documentation must include the name of the participant, the date of training, training title, name of Trainer or organization, and , if applicable, the OCC assigned approval number.) Files must be less than 2 MB. Allowed file types: txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml. Training Title * Training Date * Amount Paid * Receipt * Upload Files must be less than 2 MB.Allowed file types: txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml. Certificate * Upload Files must be less than 2 MB.Allowed file types: txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml. Add one TOTAL AMOUNT REQUESTED * All information on this application is true and accurate to the best of my knowledge. I understand that any false statement on this application will result in being denied reimbursement; being required to repay the amount reimbursement; and/or no longer be eligible for training reimbursement. Applicant's Signature Clear signature Date * Submit
