Childcare Vouchers Application Form

First Name

Last Name

Address

Employer Name

Contact Tel

Email Address

You can pay your total childcare invoice through Childcare Voucher Solutions eliminating the need to make separate payments.
Tax and NI exemptions will be applied up to the maximum of £243 per month or £55 per week for standard tax rate payers.

Value of Vouchers

Payment Period Weekly Monthly

Tax Payer Rate Basic Rate Taxpayer Maximum £55 per week or £243 per month Higher Rate Taxpayer Maximum £28 per week or £124 per month Top Rate Taxpayer Maximum £22 per week or £97 per month

Please list here all the children for whom you pay/intend to pay for childcare with Childcare Vouchers

Name of child 1

Date of Birth

Type of Childcare Used

Name of child 2

Date of Birth

Type of Childcare Used

Please enter the details of the childcare provider you would like to pay with Childcare Vouchers. Please be aware that the person must be registered with Ofsted or the appropriate registering body in your area. If you have joined the scheme but have not yet decided on a carer, you may leave these details blank.

Carers Name

Address

Ofsted Number

Contact Name

Email Address

Telephone Number

Please confirm the type of payment schemes required:

Payment Method Direct/Standing order (regular payment made direct to your childcarer) Make payments on secure website (for one childcarer) Holding Account /Authorise payment on instructions (for multiple childcarers)

If you, the applicant are accepted to join the scheme it is understood that this constitutes a contractual change to your terms and conditions of employment. You will cease to be entitled to your original salary unless you choose to opt out of the scheme due to a lifestyle change*. Instead of your original salary the childcare vouchers will be deducted from your salary. By submitting this form you are consenting to vary your terms and conditions of employment.

I have read and understood the company Agreement to Vary Terms and Conditions of Employment with regard to Childcare Voucher Solutions Vouchers and agree to abide by its conditions. I undertake to notify the company in writing, if there are any changes in my personal circumstances or childcare arrangements that would cause me to cease being entitled to this scheme.

* A lifestyle change is one that affects your child caring or employment situation.

Clicking I accept means that you agree to the Voucher Systems Limited Terms and Conditions.

I accept