TGS Childcare Grant Application

This application will be kept confidential.

Applicant must be an active, funded PhD and/or master’s degree candidate affiliated with The Graduate School (TGS). Limit two children, ages 13 & under, per family. Combined family income is $130,000 or less as verified on most recent federal tax return or FAFSA. Maximum annual subsidy is $2,500 for one child; $5,000 for two children, per year to be paid out in three quarters: fall, winter and spring ($833.33 per child).

Please complete and submit the requested information.

Questions? Please email ajdelaire@northwestern.edu.

Date of Application * / MM / DD YYYY
Parent Name * First Last
Wildcard ID# *
Northwestern School/Department *
Mobile Phone * - ### - ### ####
Email *
Name of Child *
Birthdate of Child * / MM / DD YYYY
Name of Child 2
Birthdate of Child 2 / MM / DD YYYY
Adjusted Gross Annual Family Income (from most recent 1040 Federal Tax filing) *

Tax Information:
In accordance with the IRS regulations, employer provided dependent care assistance is considered taxable income. Childcare fee assistance for U.S. students must be reported when filing your U.S. tax return. Childcare fee assistance to nonresident students is subject to 14% federal taxation and reported on Form
1042-S.

For more information, see IRS Publication
970, “Tax Benefits for Education” and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.
I verify that I am currently not receiving other University Childcare Fee Assistance this year. *
I certify the above statement is correct.
I certify that the information on this application is accurate. I agree to notify TGS immediately should there be any change in my eligibility due to student status. I understand that childcare assistance funds are not guaranteed and are based on available funds at the time of application. A childcare grant application must be submitted for annual consideration. *
I certify the above statement is correct.
You must submit the following documents as a single, scanned PDF:

• Most recently filed, household Federal 1040 Tax Form. Only first and second, signed page of Federal return. State return not required. Redact social security numbers and bank information before submitting.
If a 1040 not filed, provide complete FAFSA with adjusted gross household income information.

• Recent invoice with childcare provider’s name. If invoice is not available, please refer to the template in the FAQs.

• Copy of child(ren) birth certificate(s).

FAQs with provider template: https://www.northwestern.edu/hr/benefits/work-life/paying-for-childcare/tgs-childcare-grant-faqs-updated-sept-25-2017.pdf
I understand that my application will not be processed until TGS has received all requested documents.
Upload Your Required Documents as a Single Redacted PDF *

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