Child Care Provider Stipend Check Request
The information entered into this form is confidential, secured, and shall only be made available to employees of the Foundation for California Community Colleges (FoundationCCC) with an express business need to provide service. The FoundationCCC causes the data you input to be encrypted (coded) when en route between your browser and the FoundationCCC's database. While residing on FoundationCCC's database, the information is password-protected and access to your information shall only be provided to certain personnel at FoundationCCC who need access to administer the requested services.
Name (as shown on your income tax return)
Business Name/Disregard business name (if different from above or operating as an individual)
Check appropriate box for federal tax classification of the person whose name is entered above.
Individual/sole proprietor or single-member LLC
Limited liability company
Enter the Tax Classification (C Corporation, S Corporation, or Partnership)
Please enter a valid phone number, including area code.
Street Address Line 2
State / Province
Postal / Zip Code
Individual Taxpayer Identification Number (ITIN)
Enter your ITIN in the appropriate box. The ITIN provided must match the name entered above to avoid backup withholding. For other entities, it is your employer identification number (EIN).
Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)
Employer Identification Number (EIN)
Date of Signature
Should be Empty: